Is access possible in tough markets?

In the 1990s, the promise of healthcare reform and the rise of managed care created unique markets, where the business of selling pharmaceuticals has been at the mercy of often unknown pressures. These market fluctuations have created physician access trouble for the pharmaceutical industry, and tricks of the trade no longer get reps through the door.

Though all reps face access challenges, market and territory pressures play a critical role, according to Rayna Herman, managed care and product strategy consultant with Health Strategies Group and author of the group's 1999 report, "Access to High Prescribers: The World of Doorknob Details." The report enumerates many factors that contribute to access problems, including policy restrictions, managed care population, physician consolidation and practice size. These factors all translate into reps having difficulty gaining access to high prescribing doctors or losing physician contact time altogether.

MANAGED CARE

Traditional managed care markets, with high levels of managed care penetration and physician consolidation rates, are generally considered tough markets. "If you look at markets like Southern California or Seattle ... they have a lot of physicians in advanced physician organizations," said Herman. "They've got these very sophisticated medical groups, which are kind of a channel in between the pharmaceutical manufacturer and the physician." This channel, according to Herman, can be thought of as another customer - someone reps must keep in mind while they focus on the prescribing physician. "You've got the medical groups in those markets developing policies which restrict representative access [and] restrict sampling … these groups develop their own guidelines and their own preferred drug lists."

Issues specific to advanced managed care markets – for example, dissolving physician groups in Seattle and Denver – are an emerging concern. "When you look at Denver, there were all these large physicians organizations that have now dissolved, and what you have is a lot of confusion on the parts of the physicians, so in a way, they're distracted," Herman said. "And I think it's got to be even tougher to be in a market like that where you don't know who's around anymore, who are the customers, who are they affiliated with, and are they going to be around next week? How do you decide who's the priority? I think that adds another whole level of confusion."

"Let's face it: Most doctors are very good doctors, but they don't get professional training in how to operate a business," said Sarah Lenoue, Seattle-based senior executive sales representative for Glaxo Wellcome's Cerenex division. "You have business-oriented people who really are looking at numbers and body counts and everything else to make ends meet, and the physicians really just want to take time with their patients and give them quality care - and that's where the stress kicks in." The financial aspect, coupled with an influx of new reps to a small physical area makes Seattle's managed care-heavy market one of the nation's toughest. "There has been a lot of turnover and inconsistencies within plans and providers and institutions." Lenoue said. "A lot them have closed and relocated."

In some markets, like Boston and even St. Louis, where managed care penetration is high but physician groups may not be as consolidated, access problems are driven by another pressure source. "What you have is highly academic-influenced markets where there is a high concentration of academic and research centers, where physicians can say 'Oh we don't trust the information that the pharmaceutical manufacturers are giving us,' or 'We don't have time to see the reps - we don't really see them as being viable,'" said Herman. "In those places it's harder to get in and convince the physicians that the representative has value in terms of scientific information."

TOO MANY REPS?

The nationwide sales force increases constitute another contributing factor to the access problem, often exacerbating specific market issues. In Seattle, where most of the city's hospitals, major clinics, and doctors are located in the same, two-mile area, Lenoue worries about the market being overrun by drug reps. Said Lenoue: "The pressure is on them to see more patients in a limited amount of time, and then here we come though their door, one after the other, after the other - that's why we've had to get real creative with how we're seeing physicians here because there's not enough time."

Lenoue added: "The key to access has been that we've just had to coordinate our schedules almost down to a science to do two things: One, to make us more productive and not kill each other, and Two, so we won't offend the physicians by being there more than we should."

SOLUTIONS

Reps can only take on access issues after they have learned about the constraints on their particular markets. Market-based access information is very important for individual reps: "Understanding the reasons behind why they're having these access policies will help you become a more effective representative in terms of demonstrating value," explained Herman.

At the individual level, one access solution is to focus on and demonstrate the value reps provide. According to the report, providing samples is one tangible service reps - and only reps - can provide their physician customers. Another is information. "Physicians do find the information and the samples valuable," Herman said. "For an average primary care physician to actually know the details of every new product that comes out is a lot, so a person who knows the product in and out and is able to come and tell you about it is a service."

Most drug companies' managed care training for new reps fall short, said Herman, with an industry average of 1.9 days of managed care/market training versus 50 or 60 days of sales training. Herman explained the inadequacy. "Our impression is that [the training] is primarily driven by things like terms, for example, 'What is an HMO? What's a PPO?' or 'What's a 3-tier copay?' but not necessarily, 'Let's look at healthcare,' and 'What's happening in this market?' and 'What does it mean now for the physicians?' I definitely see that as being an opportunity."

Manufacturers also can approach the issue by rethinking traditional sales and compensation models. "The one-rep-to-one-physician kind of traditional pharmaceutical marketing model - maybe that's not going to be the primary model in every market." Herman explained. "Maybe in places where you have academic centers you end up with physicians selling to those thought leaders because [doctors in those markets] are going to respond better to a medical message. Whereas maybe in Southern California, you have a businessperson selling, because [doctors in those markets] are dealing with more financial pressures."

According to Herman, however, changes like these are happening slowly. "Companies will become more proactive in looking at the world regionally and saying maybe we should have a different approach across these markets," she said. "Right now it's just happening in pockets, but in the future, [market-driven sales models] will be more headquarters-driven."

PROS

Behaving professionally and respectfully of physicians, their staffs, and other representatives, is something reps can do collectively and across product lines to retain access - even in the toughest markets. Said Lenoue: "We're having to go back and re-educate reps on the common courtesies."

Lenoue serves as president of Pharmaceutical Representatives of Seattle, a two-year-old rep association formed to join forces on a profession-wide level to combat the tightening Seattle market. This year, the association has hosted speakers from each of the major Seattle clinics to share the clinics' protocols for rep behavior, and is planning a fall symposium on how reps can work better with clinic practice managers. "If we're cohesive as a group, take a stand and can at least do the footwork - get the information out - that's what's going to help us all in the end." Concluded Lenoue, "There's plenty of business for all of us out there if we treat each other professionally." PR