Cause and Effect—Sales Rep Visits and Physician Prescribing Habits

A new study suggests that physicians who see fewer reps are slower when it comes to dropping ‘black-box’ drugs-and at adopting promising new medications.

If you’ve ever had any doubts about whether your sales reps are actually affecting the prescribing habits of the physicians they visit, a new report by ZS Associates, recently reported on in The Journal of Clinical Hypertension, may be a real eye-opener. The study looked at the prescribing behavior around the launch of a new drug, which it called a “positive event,” and around a drug that was newly given a black box warning, which it called a “negative event,” and measured physician prescribing behavior for each of these events. Pharm Exec spoke with one of the study’s authors and ZS Associates managing principal, Pratap Khedkar, to find out more.

Pratap Khedkar: Of course when these events come out physician behavior changes, but we wanted to know, to what extent would the change in behavior be affected by general sales rep access policies in that physician’s office? We also have the reaction in prescribing times for each of these events. And we wanted to see what the connection was between the two.

PE: How generalizable are the results of the study to other drugs or other physicians?

PK: We had a physician sample of 60,000 to 70,000 physicians, including specialists such as cardiologists and endocrinologists as well as primary care physicians (PCPs). We feel pretty confident that our general data should be projectable to other events. All of the previous studies so far have been more anecdotal-with a small group of physicians, where you ask them how their habits have changed, ask them about access, and try to come up with a generalization that says, “this is the impact.” We were not comfortable with the anecdotal, small-sample nature of things, as anything based on such a small sample is very hard to project to a large population.

PE: In the The Journal of Clinical Hypertension article, it says, “Optimal health decisions for patients are the result of physicians weighing the value and relevance of medical and marketing information from a variety of channels, on top of their own training and experience.” But aren’t there particular laws that restrict reps from sharing “medical information” with physicians?

PK: It’s not that the rep is not allowed to say anything medical-he’s just not allowed to say anything that is off-label. Once we’ve decided that yes, the rep is allowed to discuss certain things, the second question is, should the rep be allowed access to the doctor in order to say it? One of the goals of our study was to show that access restrictions might have some unintended consequences. So the people who are making these policies need to take that into consideration.

PE: It sounds as though the lower the access to sales reps, the slower the physicians were in doing away with black box medications or to adopting new promising medications. What are the implications in terms of patient outcomes?

PK: Physicians get their information from many sources, and I want to clarify that it is not that we are saying that they should get their information primarily from sales reps as a source. They get information from their peers, from their journals, from their own expertise, their social network, or websites. Our conclusion is that the rep is one of the tools in this arsenal of choices or channels.

We also found that primary care physicians seem to be more dependent or more affected when the rep access dies down. Why? Look at the life of a typical specialist versus a primary care physician. A specialist working in a particular area will have to remember maybe 25 brands, in terms of knowing the news. And what’s important isn’t just knowing something about this brand from 10 years ago. The idea is that if something happened in the last couple of months in the news, are you keeping current with all the developments of all the brands that you have to remember as you confront the patient? And while a specialist has to keep track of a small set, a PCP might very well have to keep track of 100 or 200 brands. And that’s a lot of things to keep up with. It is impractical to expect that the PCP will deliberately and actively seek out information and news for 200 brands every few weeks as news develops.

So you can’t really rely on the fact that the “pulling of information” model will work for every PCP. They’re really busy people. And when the pull model doesn’t work as well for the physician, they’re actually quite open to the rep coming in and telling them about new data or new events in a particular therapy area. And then the physician gets just enough information to say, “Aha, I need to go find out more.”

So in terms of implications, what will happen if this continues? I would say that the impact on the PCP is the highest. And that might be okay if the PCP was just the gatekeeper, right? So if the PCP said, “I’m just going to direct the patient to the right specialist, since the specialist has the best information and they are typically up to date, and I’ll let them make the prescribing choice.” But that model-even though it may come in the future because of ACOs-is not really here today. In a lot of these areas that you’re talking about today, like diabetes, heart disease, mass markets in general, PCPs are doing a lot of the decision-making and the prescribing themselves. And so we have to find a way-the healthcare system has to find a way-to make sure that the PCPs are in command of all the information they need. The idea isn’t to influence the prescribing choice; the idea is to provide all the information the PCP needs to know, positive and negative, for all the products that they might pick from, so that they can make the right choice.

PE: There was a specific sentence in the journal article that stood out: “Policies that promote physician ignorance of new medical information resulting from access limits run counter to protecting patient health.” Can you comment on this concept?

PK: That particular sentence was a quote from one of the other study authors. We did not, to be very clear, analyze the actual impact on what happened to the patient. We did not have the data on which patient was this affecting, and therefore what happened to the patient. For instance, if a patient was not pulled off of Avandia on time and they were left on it for several months, if they would have some unfortunate medical outcome, we don’t know. So we are not saying that we have the evidence to show that patient health was compromised. I think what we are saying is that we did that the prescribing habits were different among those with rep access than among those without, so it could be that as a result-and this is speculation-that the patient health was affected.

I think the focus of the message is that when we limit information, there may be unintended consequences on patients and patient health. And that needs to be taken into consideration. I think the other element is that policies that have come up with access restrictions have implicitly assumed, without a lot of empirical evidence, that there is only a down side in allowing access, so if we stop it, then the reps just go away and physicians have more time for patients. That’s all great, but these restriction policies assume that there is absolutely no down side to it-that there is no negative impact on restrictions at all. And what we’re trying to show is, let’s go back to the data; let’s not argue it based on anecdotal opinion. Let’s take large empirical data and see whether or not there is a negative impact. And yes, there is a negative impact to access restrictions. There could be a positive impact to the restrictions as well, and so policymakers have to weigh both the pros and cons.

PE: When you consider the pros and cons-perhaps more informed physicians with more sales rep visits, versus less time for patients-what can you suggest?

PK: Balance is absolutely the right word here-we are not recommending any extreme, either total access or zero access. I think both extremes are bad, as is usually the case in the real world-you always need balance. If it’s a mass-market therapeutic arena, if there are a lot of newsworthy events happening with drugs in that market, and if there is a large PCP population that’s making a lot of prescribing decisions, then these pros and cons should be considered. On the other hand, if you have a drug that is only used by 300 physicians, and these 300 physicians know it inside and out, then not having access may not be such a big deal.

Of course, it’s paradoxical that in those areas where there is a very small universe of highly specialized people, they actually do welcome reps, because they have the time to sit down and have a half-hour long, in-depth discussion. They don’t have too many reps coming into their office anyway, because they have very few brands that they even write. And so they don’t feel like it’s a big drain on their time. So they have very meaningful conversations. And it’s paradoxical that the more specialized the profession gets, the less is this issue of rep access coming to the forefront. I think it’s a bigger issue in the PCP space, where that’s exactly the kind of doctor that’s so harried and so busy that they don’t have time to go seek the information. And if the rep is a good way to at least give them that initial piece of information, why not utilize that?

In terms of those pros and cons, the policymakers have to consider, well, maybe we can restrict the access just a little bit. So instead of high access, we make it medium. Maybe we can discipline and streamline the process so it’s not that reps are coming in 60 times a year just to talk about the same product again and again. Again, there is a happy medium there. And the happy medium may be different by physician group, it may be different by size of the practice-my point is, it’s a nuanced decision. And all we are recommending is that people take the time and exercise the objectivity to make that nuanced decision.

PE: What would you say the takeaway is for pharmaceutical companies?

PK: I think one thing that they have to recognize is that access has become worse over time and it’s going to continue to get worse. About 11 percent of physicians in the US in 2010 were no-see or very little access, with very severe restrictions. And another 34 percent had some access, and some restrictions. So that total number is creeping up to the halfway mark.

For pharma companies, I think their goal, as always, has to be to present the approved information to the physicians. Maybe the way they do it is to make sure other channels of information are available. So for the physicians that absolutely do not want to talk to the rep, there must be some other way of getting this information to the doctor. Perhaps the doctor says. “I don’t like to see reps because they distract from my time during the day, but I’m okay with having a rep conversation at the end of the day.” So time shift it-talk to physicians when it’s convenient for them; don’t try to interrupt them in the middle of trying to see 30 patients a day. Many companies have set out a way to do an E-detail, a videoconference, or an email, at a more convenient time, using an iPad. It’s convenient, it’s not interrupting you as the physician, but it is making sure that you get the information you need, so that the next day you’re not left feeling like there are things you didn’t know at the time you made your prescribing decision.

And it’s not only having a broader multi-channel approach, but also making sure to tell the doctor that the multi-channel is available. Because the big issue we find is-you can create a website, and every brand has a brand.com, and they put all this information on there, but nobody visits it. Because no busy doctor is going to say, “Okay, there are these 400 drug branded websites, I need to figure out which websites to go to and read up.” They don’t even know which questions they should be asking.

The answer, as always, is that you need the right balance. It doesn’t have to be all push through the rep, it doesn’t have to be all pull because the doctors won’t do that. What is the right mixture so that both the doctor and the pharma company are happy?