Back to the Future?

Like Marty McFly, the character played by Michael J. Fox in the movie Back to the Future, pharmaceutical companies may need to go back in time to assure their own future. McFly was a time-traveling 1980s teenager who landed unexpectedly in the 1950s, and discovered that he needed to spark a romance between his parents to assure his future birth. The problem pharma companies face, if less existential, might be equally baffling for today's sales departments. After training a generation of sales reps and managers on store-bought physician prescribing data, sales executives face the possibility that their data supply may dry up. If it does, pharma has to remember how it used to sell to doctors—before anyone had the luxury of databases full of prescribing data.

In reality, this is not yet a big problem. New Hampshire, which passed a law to ban the use of prescribing data, represents less than one percent of the nation's market for prescription drugs. And, so far at least, physicians enrolled in the American Medical Association's PDRP program are but one half of one percent of the AMA's 800,000 members. But the danger signs are out there, and it might be time to think about future—and past—selling strategies.

If access to physician prescribing data continues to decrease, the just-look-it-up mentality of too many sales reps will, by necessity, become a thing of the past. But as someone who has worked 15 years in the industry, I'm here to tell you that the way of the past—developing sources in a community and crafting a sales strategy with the information they disclose, helped make me more efficient and enabled me to respect my customer's time. Back in the day, when I carried the bag, I started out with little information about a new territory besides zip-code sales data. I did fine. And if data granularity disappears, the sales representative of the future can still succeed.

Don't get me wrong. I do not prefer the old ways to what we do today. Since the mid-1990s, pharmaceutical companies have built practically all of their sales operations and business processes—from targeting, physician segmentation, sales-force automation systems, and incentive-compensation plans—on prescriber-level information they purchase from data aggregators like Verispan and IMS. This information allows pharma to identify the prescribing patterns of specific physicians and decide where to focus sales activity. The data enables reps and their supervisors to pinpoint messages and develop valuable medical information that is customized to the prescriber—thereby offering more value to patients and themselves.

A Sales Rep´s Tangled Web

But as wonderful as this data is, pharma can relearn how to live without it. Sales managers should still be able to adjust business practices, run departments, and train sales representatives—even if we have to work the way I did, when I first became a rep.

Zip-Code Data

When I was a sales representative for McNeil Pharmaceutical in 1991, I received zip-code data every month. The data broke down product sales for my medications and competitors by zip code throughout my territory. My first step in analyzing the data was to compare the new numbers to the previous period, to gauge any changes. I then calculated my net-to-market (my product's percent growth or decrease minus the market's percent growth or decrease for the period) to assess overall progress. The net-to-market gave me a context for my product's growth or decline. Then I had to rely on my business acumen and local-market knowledge to help identify the key high prescribers or the ones who gained or lost market share. It was at this point that I was able to assess the effect of my targeting.

Selling to doctors using zip-code data resembles how a hospital representative sells to hospitals, residency programs, or long-term-care facilities. These reps start with Drug Distribution Data that lists product sales as well as the therapeutic classes the product competes in. However, the data do not show who the big subscribers are or how they affect overall sales. I call these physicians "key doctors," who need to be researched within the account. In order to identify key doctors, reps should pay careful attention to relationships within the account environment, including support sectors such as nursing, library services, microbiology, pharmacy, medical education, and so on. The support areas will vary depending on the disease state in which the product is used. For example, if a rep sells an antibiotic, she ought to cultivate close relationships with the microbiology lab, pharmacy (including floor pharmacists and PharmD consultant pharmacists), infectious disease, nursing (especially the charge nurses for each shift), the quality-assurance-committee members, and possibly the intensive-care-unit staff. Developing information from these sources to identify key physicians is account-based selling.

Doing the Research

Applying account-based selling strategies can help a sales rep compensate for the lack of prescriber-level information. The information-development process in the community setting is similar to the hospital strategy, although the players are slightly different.

An excellent first step is qualification. Every prescriber or group practice should be analyzed based on their potential to influence the products a rep sells. This is what qualification will do:

• Identify customer needs for your products
• Assess customers' financial situations
• Identify compelling events that may drive decisions
• Outline the decision process
• Document the relative sales value
• Critically assess current relationships in the account.

The sales representative begins by assessing the extent to which a particular customer or group has defined a need for the products. For example, a rep sells a drug for osteoporosis, which is generally an affliction of the elderly (steroid use notwithstanding). The rep may not want to target a pediatrician because at first glance it may not make sense. Unless, of course, the doctor also uses the pediatric formulation of one of your antibiotics, and is good friends with a rheumatologist, whom you have not been able to meet. The pediatrician may provide an introduction. In addition, you have also learned by speaking to the DEXA scanning technician that this rheumatologist orders a lot of these tests and many of them are positive for osteoporosis. (DEXA stands for Dual Energy X-Ray Absortiometry, and is currently the most widely used method to measure bone mineral density, a key diagnostic indicator for osteoporosis.) Qualifying a doctor means understanding his relative potential, including his relationship to your entire business. The pediatrician, in this scenario, might help you gain access to the rheumatologist.

Next, the sales representative should understand the roles and responsibilities of personnel within the office. It is especially important to know whom the physician relies on most to get things done. By understanding everyone's role—nurses, billing, coding, and front office—the sales representative will improve her sensitivity to each person and be able to incorporate this into her message.

Once the physician is qualified and relationships within the practice are understood, the rep should consider how specific Health Maintenance Organizations (HMOs) or Preferred Provider Networks influence prescribing behavior. Marketplace drivers, such as specific plans, have increased their influence over prescribing behavior, primarily through the use of closed formularies. Medications not on the formulary may be unavailable or accessible only through a rigorous prior-authorization process. The relative impact of this varies by physician and plan.

If a physician has a large patient population in an HMO with a strict formulary-adherence policy, reps need to understand how this may affect the physician's prescribing. For instance, if the rep's product has a prior authorization, and it is time consuming for the physician to write an alternative product, the rep may never get—or even need—a chance to compare the efficacy and safety of her product to that competitor. A three-dimensional view of this selling environment must take account of formulary availability, including the plans your respective customers participate in and the percentage of patients represented in each plan—and finally, how these plans influence the physician or his/her office staff. All of these elements together will help the sales representative identify and reach the most responsive targets.

Just look at the following example: My wife is an internal medicine physician. Her clinic administrator once asked her how she treated asthmatic patients. Her reply reflected her minimalist, common-sense approach, which invites patient participation in the treatment and medication plan. She relied on patients to tell her how they felt and how well they responded to medication. When the administrator wanted to know how often she performed a certain test, she said that she ordered it only when the patient was non-responsive to the prescribed treatment and medication plan. The administrator suggested that she (my wife) should order the test every six months, because that's how often the practice could bill for it.

Some physicians cave to the financial pressures to order unnecessary tests, while others prefer to cite data supporting their position. Understanding the pressures on a physician may help a sales representative to position products within that doctor's practice. A rep with an asthma medication may be able to help the doctor by providing data to support a minimalist approach.

Spider Diagrams

As a hospital sales representative, I mapped the relationships that were important to each physician on something I called a "spider diagram." The diagram charted relationships like these: I once played poker with an urgent-care doctor who introduced me to one of my hard-to-see internal medicine physicians. He, in turn, introduced me to another hard-to-see internist, with whom I later trained to run a marathon. So I had four hours of one-on-one time every week with a no-see doctor because I leveraged a cascade of relationships. In addition, I met a new friend who, in turn, expanded my network even further. Using a spider diagram to show how doctors relate to each other and the world around them helps reps identify key doctors without using specific prescribing information. This does not require inappropriate influence. The rep simply gets to know the doctor, maps the doctor's interaction with the environment, and shares specific product-related information for the doctor to objectively consider. Mapping enables reps to incorporate new levels of insight in order to better share information. Analyzing these relationships helps the sales representative build a complete picture of the customer, both within and outside the unique medical setting (see "A Sales Rep's Tangled Web,").

The Road Forward

It would not be easy for a vast number of sales representatives to apply account-based selling strategies in the community setting. However, every sales representative may have to do this if prescriber-level data is no longer available. The data they obtain by qualifying physicians, understanding the impact of health plans, and mapping the relationships of prescribers will enable them to succeed without modern databases. It's hard but it is not impossible.

The sales representative is not the only one who will have to change. The entire organization will need to retool. Sales training departments will have to teach business acumen and explain how account selling works in community settings. Sales management may lack the experience or skills to advise direct reports on how to use these techniques. Operational departments may need to develop new ways of recommending targets to field management and sales representatives without communicating prescribing information. For this to succeed, however, the sales force needs to trust in operations. The proverbial "the data is wrong" argument will take up valuable selling time and attention, especially if the sales representative is unable to confirm or deny this information through the successful implementation of account-selling techniques.

Sales representatives will have to develop new levels of teamwork with their peers. As data becomes less specific, it will be more important for them to work closely and share "pearls" of information. Many organizations have multiple sales reps calling on the same doctor. A piece of information has maximum impact only if it is shared and applied by everyone. Sales-force-automation systems may need to be altered to help reps build information sources for each prescriber. Without this ability to accumulate data about each physician, information may be lost.

No one wants to go back in time. But the possibility exists that pharma's future may resemble the past. PDRP, if it becomes a widely used program, will add old but familiar challenges to sales reps' jobs. Without comprehensive databases, sales representatives will once again become the best source of information about a prescriber. Reps' sensitivity to a doctor's unique marketplace, and their awareness of the pressures on physicians in their territories, makes them greater assets in the customer's eyes. By applying account-based selling techniques in a community setting, sales reps should be able to overcome the challenges of PDRP and state legislation, as they develop a better idea of who their key players are. And unlike Marty McFly, sales reps can prepare to meet the challenges of a new environment that may closely resemble the past.

"Old timer" Scott Hull is associate director, sales and marketing, at CV Therapeutics. He can be reached at scott.hull@cvt.com