Doctors have long maintained that they are immune to the blandishments of drug companies. The lucrative consulting contracts, fancy meals, trips to exotic locales, free pens, flashlights, coffee mugs, and sticky notepads emblazoned with prescription-drug brand names—none of these are supposed to cloud a physician's clinical judgment. Doctors like to think they decide which treatments to order and which drugs to prescribe because of scientific evidence, not marketing.
But the companies think they know otherwise. Last week, five whistle-blowers from government and industry gathered in Washington, D.C., at a meeting sponsored by the online scientific journal PLoS and the Government Accountability Project to discuss the pharmaceutical industry. Among the attendees were Kathleen Slattery-Moschkau, a former drug company representative and independent filmmaker, and an unnamed drug company researcher. They detailed for the group how the companies and the reps know—right down to the pill—whether or not their sales pitches are working and how to improve them. The industry's semi-secret weapon is prescriber reports, weekly lists of every prescription written by each of the 600,000 doctors in the United States. Relatively few physicians know about prescriber reports, also known as prescriber profiles. But their existence makes it far more difficult to imagine that pharmaceutical marketing has no effect on the doctors it targets.
Prescriber reports became possible in the early 1990s. First, pharmacies began processing insurance claims by computer and peddling the data to the pharmaceutical industry and to clearinghouses, like IMS Health, which then sells information about the drug market. The pharmacy records don't include the names of patients or doctors: They are coded with physician ID numbers, which are issued by the Drug Enforcement Administration so that it can track controlled substances, like morphine. But drug companies and IMS can buy lists that match the DEA numbers to doctors' names from the federal government or the American Medical Association, which earns about $20 million a year selling its "physician master file" database. The master file contains personal and professional information about every doctor in the country, including their DEA numbers.
By putting together all of this information, the weekly prescriber reports can show the names of the doctors in a rep's territory and what each doctor prescribed and how much of it. Reports provide reps with up-to-date feedback on just how effective they've been in persuading their doctors to prescribe the two or three drugs each rep pitches. The reps are schooled for weeks in a variety of sales techniques. They memorize tightly crafted speeches and volumes of data on their products, and some are even trained in personality profiling, to help them guess whether a physician is more likely to respond to reams of scientific research or to schmoozing. Prescriber reports play a key role in helping reps boost sales—they're like weekly focus groups that help reps shape their pitches to individual doctors. If Doctor A increased her prescriptions after being treated to a facial and full-body massage, more expense-paid spa excursions are in order for her. If Doctor B didn't respond to a courtesy five-course meal, then maybe it's time to try football tickets, or up the free drug samples, or plug clinical research that touts the proffered drug's benefits.
Prescriber reports also allow reps to identify and target their top prescribers. The reports rank doctors into four tiers, based on how many scripts they write. Reps focus most of their energy on the upper ranks—the doctors who write hundreds of prescriptions per month. That's because a rep's bonus depends on increasing market share, the sales of his drugs in his territory compared with competing medications. Getting top prescribers to increase their prescriptions by even a few percentage points can give the rep that needed boost.
From the companies' perspective, hard-sell tactics are simply good business. Pharmaceutical manufacturers spend hundreds of millions of dollars getting a single drug to market. Once it's there, they try to move as much product as possible before the drug reaches the end of its patent life, usually within a decade.
What's harder to understand is doctors' insistence that they're unmoved by the approximately $15 billion that drug companies spend annually on marketing (compared with $33 billion a year on research and development). Plenty of evidence shows that they're easy marks. Several published studies have found that doctors who rely on reps for their information have more expensive prescribing habits than those who stick to the medical journals. Besides raising costs, taking a company at its word about the merits of a drug can hurt patients. One study published in the New England Journal of Medicine in 2001 revealed that patients who used the painkiller Vioxx were five times more likely to suffer a heart attack than users of the generic drug, naproxyn. Yet that year, Merck & Co., Vioxx's manufacturer, managed to make the drug's sales rise faster than the top 10 drugs in the industry, with revenues topping $2.6 billion. How did that happen? Merck documents submitted to Congress after Vioxx was withdrawn from the market last fall show that the company taught sales reps how to deflect doctors' questions about the painkiller's safety. The reps handed out "cardiology cards," pamphlets that used studies less powerful than the one in NEJM to make it look as if Vioxx was associated with fewerheart attacks rather than more. Merck code-named its marketing blitz "Offense" and "XXceleration."
Most physicians make "I'm OK, you're not" assumptions about their profession's susceptibility to such tactics. In one survey, 61 percent of the residents at the University of California, San Francisco Medical Center reported that they themselves are unmoved by drug company gifts. But when asked if they thought their colleagues were swayed, 84 percent said yes.
Perhaps revelations about prescriber reports will persuade doctors that they should think seriously about how hard they're being spun. Physicians who find out about the reports by word-of-mouth at medical conferences, or in the occasional medical journal article, often say they feel their privacy is being invaded. They worry that the pharmaceutical industry's extensive data collection violates doctor-patient confidentiality (though they can't say precisely how, since patient names are not included in the reports). Some have booted drug reps from their offices when they've learned of the reports. "Telling your doctors how much you really know can be the kiss of death," said Slattery-Moshkau, the former drug rep whose indie film Side Effects is about her decade in the business. Maybe what's most disturbing to physicians is that the prescriber reports make it hard to go on pretending that science always trumps marketing.