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Making the Unsales Pitch

SalesThe latest effort by state governments to reduce prescription drug spending attempts to beat the pharmaceutical industry at its own game.

States, including Pennsylvania, West Virginia and New Hampshire, are training and employing representatives to visit doctors’ offices and deliver “unsales” pitches.

Question: What is an “unsales” pitch?

While representatives that deliver unsales pitches also visit doctors one-on-one and carry graphs, charts and fast-facts like their counterparts from the pharmaceutical industry, they have a different agenda.

The purposes of an unsales pitch are to:

  • explain to doctors that generic medications or older versions of new medications are just as effective as name-brand pills in treating various diseases,
  • counsel doctors about the specific cases where foregoing prescription drugs might be a viable alternative, and
  • encourage doctors to prescribe the least expensive treatments whenever possible.

The mastermind behind unsales pitches is Dr. Jerry Avorn, a physician and professor at Brigham and Women’s Hospital, a teaching affiliate of Harvard’s medical school.

Dr. Avorn believes that the only way to reduce the influence of pharmaceutical advertising on prescription drug spending is to provide doctors with unbiased information in these one-on-one unsales sessions.

Question: How does pharmaceutical advertising influence prescription drug spending?

First, pharmaceutical marketing drives up the amount spent on prescription drugs.

  • Prescription drug spending is a relatively small portion of national health care spending (10% in 2004), but it is one of the fastest growing components.
  • Prescription drug spending is increasing for three reasons:
    • Greater use of drugs overall,
    • Increased use of newer, higher costing drugs in place of older, cheaper drugs and
    • Manufacturer price inflation for existing drugs.

Pharmaceutical advertising is also directly responsible for the use of newer, more expensive drugs.

This is because the pharmaceutical industry spends vast sums on both direct-to-consumer and direct-to-doctor advertising to market its newly developed products.

  • Pharmaceutical companies spend $19 billion per year worldwide on marketing campaigns, $7 billion of which is directed towards doctors.
  • Direct-to-consumer ads encourage individuals to “ask their doctor” about newly developed medications, which leads to patients visiting their doctor and requesting prescriptions, even if they don’t need to be taking anything.
  • This form of advertising is one of the main reasons that prescription drug usage has skyrocketed in recent years.
    • From 1994 to 2005, the number of prescriptions purchased increased 71% (from 2.1 billion prescriptions to 3.6 billion), compared to a U.S. population growth of around 13%.
    • In 2006, the number of prescriptions per person (both new and refills) bought in retail pharmacies, ranged from 6.5 prescriptions in Alaska to 17.2 prescriptions in West Virginia, with a U.S. national average of 11.1, approximately one prescription per month per American.
  • When it comes to direct-to-doctor ads, the industry tends to present skewed or biased information during one-on-one sales pitches with doctors.  Sales representatives are unlikely to discuss the efficacy of older, generic medications in comparison with new drugs since the purpose of their visit is to help increase sales and make profits for the drug company and its shareholders.
  • Unfortunately, even the most conscientious doctors are pressed for time when it comes to doing their own comparative research between drugs.
    • Direct-to-doctor advertising tends to increase the number of prescriptions written for new, name-brand medications as a result.

In comparison, unsales representatives use unbiased information to show doctors that generic and older medications are often just as effective as their name-brand counterparts (and that there are many conditions where it is just as wise to go without any medication at all).

Question: Are generics or older versions of brand-name drugs just as effective?

More often than not, the answer is yes. Only 35% of the 1,035 new drug applications introduced between 1989 and 2000 represented real medical improvements.  The rest were me-too drugs: no safer or more effective than drugs already available (but certainly pricier).

In fact, the FDA currently allows new drugs to be less effective than current drugs as long as they’re more effective than a placebo. And generic drugs are simply imitations of their more-expensive counterparts that are produced as patents become outdated.

Question: How will unsales pitches rein in prescription drug spending?

The hope is that doctors will use the information given during unsales pitches to prescribe cheaper medications, or forego writing a prescription altogether.    If doctors changed their prescribing habits on a wide scale, it could help to reduce overall spending on prescription drugs, both for individual consumers and for the government.

  • Doctors are often happy to receive the information.  It allows them to write a cheaper prescription for a patient and be sure that the quality of care is the same.

Question: Why is Pennsylvania spending taxpayer dollars to fund an “unsales” program?

While individual consumers pay for the majority of drug spending, government programs that assist consumers (like Medicare Part D) have seen their costs increase exponentially.

  • 21.5% of spending on prescription drugs is paid for by the government, with many states spending a sizable sum of their budgets on prescription drug plans that aid Medicare recipients.
  • Pennsylvania contributed $338 million in 2006 to cover Medicare Part D prescription benefits for the nearly 360,000 elderly enrollees in the state.  This amount has increased by 30% in the last decade.

In an effort to reduce the state’s spending on the prescription drug program, Pennsylvania invests $1 million annually (since 2005) to run the Independent Drug Information Service (IDIS).    The IDIS employs 11 “unsales” representatives, whith is just a fraction of the 90,000 representatives employed by drug makers.

Question: What is the result in Pennsylvania?

While the verdict is out on whether unsales programs are more cost-effective than other measures used to reduce drug spending, the Pennsylvania program more than pays for itself in savings.

Question: Are unsales pitches a smart use of government resources that reduce pharmaceutical influence and cut program expenses, or are they an example of unnecessary government involvement in the marketplace?

Feel free to post your response below.

More on the steps that hospitals, providers and different branches of government are taking to reduce the influence of pharmaceutical sales representatives on prescribing practices to come…

{ 2 comments… add one }
  • Dan February 28, 2009, 4:07 pm

    Published on: http://www.pharmagossip.blogspot.com
    While the pharmaceutical industry’s image and reputation has and appears to continue to suffer, added damage has expressed itself with costly patent expirations with certain large corporations within this industry in particular.
    As the president of the lobbing group for the industry which is called PhRMA would likely concur to a degree if asked, the image of this industry has experienced noticeable trauma over the past two decades in particular, and cannot be repaired by this lobbying group. The atrophy of the image of the pharmaceutical industry is largely due to how they market and sell their medications. Let’s take branded drug samples as an example:
    Even though the ability for health care provider to request samples of a pharmaceutical company’s medications to bypass the company’s representatives is possible and legal, the pharmaceutical industry, overall, prefer to have their own representatives dispense samples of their promoted medications. This also allows for the representatives to dispense inducements to certain targeted prescribers that are of a much greater monetary value than drug samples.
    These sales forces of pharmaceutical companies have been examined more now than in the past due to their unbelievable size, for one reason. The number of representatives of these sales forces of large pharmaceutical corporations tripled within a decade- starting in the mid 1990s. Also, the estimated total income for an individual pharmaceutical representative may exceed 200,000 a year, if benefits and perks are factored in to this cost. Overall, the amount spent on these reps exceeds 20 billion dollars annually by the pharmaceutical industry.
    Sadly, yet with a high degree of confidence, most big pharmaceutical sales representatives are viewed and evaluated by their employers as it relates to their ability to gift targeted prescribers. This is due to the large number of representatives promoting the same medications to the same doctors who work for the same pharmaceutical company.
    In fact, one could conclude that an individual representative in such a work environment with multiple partners with their employer is potentially exonerated from any individual responsibility in regards to their vocation. This is why they may be judged by their employers according to how much of their employer’s monetary ‘marketing budget spend’ one representative dispenses to targeted prescribers in a certain period of time. This will be further addressed later.
    Yet the inducements are never described by what they actually are, which are bribes. Who receives these bribes is largely determined by the volume of scripts the prescriber writes as it relates to the pharmaceutical company’s promoted products. The gift dispensing is also determined by the prescriber’s loyalty to a particular pharmaceutical company’s products as well.
    This data of the prescribing habits analyzed by certain pharmaceutical companies is certainly available, and this will be further addressed shortly.
    However, and empirically, the drug sampling of doctors may be considered the ultimate if not primary gift that influences the prescribing habit of a health care provider. Some pharmaceutical representatives are falsely led to believe that their territory’s performance is due in large part to their powerful ability to influence others as outstanding salespeople. Although such pharmaceutical representatives want to believe such a false premise, it is samples of medications that determine the prescribing habits of health care providers, and this has been proven.
    Many years ago, drug reps used their persuasive, yet ethical, abilities to influence the prescribing habits of doctors in an honest and credible manner. They focused on the benefits for the doctor’s patients with particular drugs that the detailer may promote to such a doctor, and how these drugs may and can restore the health of these patients.
    However presently, most health care providers now simply do not allow drug reps to speak with them, or even see them, because the paradigm had become darker than it was in the past. Medical establishments are progressively and completely banning drug reps from entering their medical facilities. This is happening for several reasons, which 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. 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.
    Also, the accurate perception of the prescriber is that now pharmaceutical representatives are more concerned by their financial health instead of the health of their patients. The health care providers do not find the pharmaceutical representatives with the knowledge they need to benefit their understanding of the drugs that the representatives promote. Any information shared by the pharmaceutical representative to them, either oral or written, is likely embellished if not fabricated.
    This view is due to the frequent statistical gymnastics the employers of drug reps engage in way too often with their promoted products, and the representatives are likely unaware of the data they have is as inaccurate as it is.
    Doctors by their very nature seek answers objectively. And doctors do in fact find out about drugs through other methods besides the representative who promotes particular drugs.
    This is further illustrated by reps being selected by pharmaceutical companies due to their perceived appearance and personalities judged by certain hiring managers of various pharmaceutical employers. Another trait desired by the pharmaceutical company is the potential candidate’s likelihood of being completely obedient to their directives, as well as their affinity for monetary gain.
    Qualities related to anything of a scientific, medical, or clinical nature is of little if any concern to most pharmaceutical companies, quite apparently.
    This is why pharmaceutical representatives have little if any interest or concern regarding public health, perhaps. This premise is further validated by the pharmaceutical employers’ minimal concern regarding the medical knowledge of their sales representatives, as mentioned earlier.
    What the pharmaceutical company is concerned with, however is the ability of their representatives to effectively offer inducements to targeted prescribers. The inducements are not gifts, but are bribes.
    Examples may be creating a check from the pharmaceutical representative’s employer to be issued to one of the targeted prescribers determined by the pharmaceutical company. This check, when given to such a prescriber, is often for doing little, if anything at all for the pharmaceutical company paying such a prescriber.
    Knowing this, it seems to validate the pharmaceutical industry’s overt apathy regarding this industry’s absence of focus regarding the essential medical knowledge of their sales representatives.
    In relation to non-monetary inducements given to certain prescribers, they may be of a certain value and are possibly without any clear medical benefit, such as TVs or DVDs, perhaps. And the autonomy that exists with some pharmaceutical companies results in authoritarian directions to their sales representatives to implement the activities with the inducements that are given again to targeted prescribers. Since pharmaceutical representatives understandably believe that since they are given such directives by their pharmaceutical employers, then they must be legal and ethical. This is further reinforced by the applause and rewards the pharmaceutical representative receives often for this behavior of giving bribes to prescribers. They are viewed by their employers as innovative and creative, instead of criminal.
    This appears to eliminate the need or desire for the pharmaceutical representative to examine the consequences potentially of some activities and tactics encouraged by their pharmaceutical employers. It is clear that most pharmaceutical representatives do not question what they are told to do.
    Targets are a result of what is referred to as data mining, which is a determining variable as it relates to who a pharmaceutical maker may choose to support financially in one way or another. Prescribing data is in the possession of pharmaceutical companies of the prescribers nationwide, and this data is analyzed to determine the prescribing habits of health care providers. This prescribing data is provided to the pharmaceutical companies by the American Medical Association.
    Further disturbing is the fact that this behavior is not prevented by our lawmakers. This data mining allows a pharmaceutical company to conclude who could potentially affect their business and therefore dispense gifts to the right prescribers for their business. The gifting establishes reciprocal relationship with the receivers of these bribes. Quid Pro Quo is now born, and the pharmaceutical company continues to thrive.
    Conversely, if a prescriber is determined by a pharmaceutical company to be harmful or of minimal financial benefit to their business, they will essentially be ignored and ostracized by the pharmaceutical company.
    While such unethical activities may appear to be ridiculous and without reason to some, this does not mean they do not occur. The illegal and unethical behaviors of certain pharmaceutical companies seem to be rather unbelievable by others on occasion.
    It seems that external regulation is necessary to prevent the drug companies from allowing this corruptive autonomy to continue to exist. It is rather obvious that internal controls of companies that perform such wrongdoing are void of self-regulation with deliberate intent.
    If regulation happens, then health it may be possible to resurrect the ethical element necessary as a participant in the health care system. The importance of public health should be the apex of their existence as a company that participates in this system.
    Overall, pharmaceutical representatives are decent and intelligent people who do not realize the results of the actions they perform upon direction are harmful to the health of others. And if they may do in fact realize what they do for their pharmaceutical employers is in fact wrong, they continue to please their employers, as financial benefit for them outweighs the results of their actions
    Fear ensures loyalty.” — Author unknown
    Dan Abshear (what has been written is based upon information and belief).

  • Dan February 28, 2009, 4:21 pm

    The Benefits of Generic Medications

    Often when one goes to seek medical attention from a health care provider, that provider usually writes a prescription for that patient for medication to either treat the symptoms of the disease that may be present, cure the disease, as with the case regarding antibiotics, or the provider may prescribe medications to delay the progression of a disease that may exist with their patient.
    The actual cost of that medication the patient receives from a pharmacy can vary greatly, and here is why:
    More now than in the past, generic medications have been encouraged and selected by prescribers at a much higher rate. Health care providers are aware that generic drugs are less expensive than branded drugs that are equivalent to the generic drug prescribed as far as safety and efficacy are concerned. Nearly two thirds of all medications prescribed to patients in the United States are now for generic medications.
    Generic medications are copies of branded medications that previously existed, yet no longer have a patent on these medications, which allows generic drug companies to produce these formally expensive drugs and a much lower cost
    Why aren’t generic medications prescribed all the time, then? The branded drugs have representatives who leave samples of these branded medications with the health care provider, with the intention and belief that this provider will select this branded drug as a result. Generic medications, while much less expensive than branded medications, do not have samples of these drugs to be left with health care providers.
    Around 4 billion prescriptions filled every year, so cost savings is rather important. Generic medications are about two thirds of this total pharmaceutical market with the drugs included in this market. However, while most prescriptions are for generic medications, this still is less than 15 percent of the total money spent on prescription drugs.
    With branded medications, about 75 percent of these newly approved drugs by the FDA are similar in efficacy as drugs that already exist in this market, so there is no benefit with many of these expensive branded drugs. Finally, about half of all newly approved prescription drugs have had serious side effects soon after they have been approved, so newer is clearly not always better, of course, as it relates to safety for the patient taking the drug.
    Most recently, certain managed health and prescription providers have been actually paying doctors to initiate if not switch their patients from branded medications they may be taking to generic medications, if possible. This may be due to a reaction caused by branded pharmaceutical companies offering similar inducements to health care providers to select their promoted medications. Both financial inducements that occur are remarkably legal, overall. Yet I find financial inducements in health care inappropriate and unethical when a health care provider treats a patient with prescribing medications for them.
    Not long ago, generic drugs were not prescribed that often, or produced to a great degree, because of the cost of bringing such a med to the market, which at the time required the same clinical trial protocols as branded meds.
    Fast forward to 1984, as this is when the Hatch-Waxman Act was introduced, and this Act only required generic meds to demonstrate bioequivalence to the branded med that they desire to reverse engineer, and nothing else was now required in the approval process that is mandated by branded medications to be completely developed and approved by the FDA. This reduced cost of generic manufacturing and approval allowed for more of these meds to saturate the pharmaceutical market, and doctors started prescribing more generic meds as a result.
    Branded pharmaceutical companies were not pleased in large part with this new act, so they devised schemes to extent the patents of their branded meds through such tactics as reformulation or combining their branded medication with another generic drug to create a new combination medication, which is called evergreening, of their meds, which allows for them to continue the patent lifespan of their branded medication.
    Additional branded drug company tactics include frivolous patent infringement lawsuits, which delays generic availability for a longer period because of these lawsuits. Also, branded pharmaceutical companies have been known to actually pay generic manufacturers to not release the equivalent of a branded medication.
    The pharmacies that fill the prescriptions for the patients written by the health care providers support generic use, as pharmacies make more money off of generic prescriptions they fill for others compared with branded drugs. So delays will not prevent the utilization of generics, overall, or for a long period of time.
    Generics seem to remain a concern to branded companies in spite of their efforts of avoiding their access, as branded companies have progressively started producing their own generic meds along with their branded ones due to the increased use of generics, or have acquired generic pharmaceutical companies entirely because of the progressive impact generic drugs are having on the business of branded drug companies.
    Also, other reasons for increased generic prescribing may be due to the awareness and clinical experience of the previous branded med that has now been replicated by the generic medication.
    Newer drugs at times are not a desirable choice of treatment for patients because of lack of confidence- as safety of these new drugs have not been overall established. This is concerning to several different health care providers. The familiarity of the generic drug accessible to them after the patent expiration of possibly the branded drug the health care provider had prescribed in the past assures the provider often that there will not be any safety or efficacy concerns by selecting such a generic drug.

    Many clinical studies have proven that generics are as effective compared with branded medications for particular disease states. The ALLHAT trial showed this, with generic diuretics showed equivalence if not superiority over the branded medications it was compared with during this 4 year trial funded mostly by the NIH. Drugs utilized in this trial were cardiovascular drugs, and the examination of these both branded and generic drugs showed that the least expensive drugs, the generic drugs, provided the most benefit for the patients studied in this trial.
    Most encouraging for even greater use of generic meds is that at least one company has created vending devices for doctor’s offices for dispensing both generic and over the counter meds. This may discourage the use of branded equivalent meds at a greater amount with generic samples available as well as the branded meds. In addition, and in some cases, doctors can order generic samples from the manufacturers directly. Both mechanisms for obtaining samples of generic drugs by a health care provider remain quite rare, however.
    Then there are some health care providers who insist that you get what you pay for, so they are convinced that branded drugs are always more efficacious and tolerable than generic medications. This misconception is a fallacy, since both forms are identical from a bioequivalence and bioavailability paradigm, as required for approval. I’m sure it’s possible others have encouraged such doctors to take such a stance void of fact and reason. However, there may be some truth to decreased efficacy of generic drugs over their previously branded equivalents, yet not to a the point where it is a clinical concern.
    In the U.S. Health Care System, cost is a rather large concern for members of the public health, and those who attempt to restore their health as it needs to be at times. Generic medications provide financial relief for patients in need of drugs to improve their health. And both the health care provider as well as the patient can be assured that a generic drug prescribed to, and taken by, a patient will provide the efficacy needed to address the medical problems of the patient. More importantly, the patient saves money, without compromising their safety,

    Dan Abshear

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