Under the Influence

UNTIL RECENTLY, BUILDING UP PHARMA'S ARMS RACE OF REPS WAS CONSIDERED a best practice. Since reps were the primary influencers of physicians' prescribing behaviors, increasing the number of feet on the street proved that companies were hard at work, with reps reaching the high prescribers with as much frequency as possible. The "mirrored" or "pod" sales force—criticized today by many—was an insurance policy of sorts back then, intended to gain greater message penetration than the competition. This approach was considered safe: Just as no one had ever fired the head of information technology for buying IBM, no head of sales at a pharmaceutical company was ever criticized for beefing up his sales force to maximize share of voice in a particular product category.

The share-of-voice model worked because the operating assumption upon which it was based was true: Reps really did influence physicians. But the world has since changed—the number of influences that affect physicians' prescribing has increased and rep saturation has reached the tipping point, resulting in "customer fatigue." Today, the list of influences includes managed care, DTC advertising and media, the Internet, government, CME and peer influence, advocacy groups, and group-practice dynamics—just to name a few. No wonder the old model no longer works.

Companies must now take into account a plethora of influences when planning their sales and marketing efforts. To that end, as companies experiment with and establish new sales models, they should think about creating a framework based not on voice but instead on influence. They should understand the key levers of influence, and how those levers work together for a given product—be they formulary restrictions, peer influence, or patient requests. In doing that, pharmaceutical companies can identify the sales and marketing approaches and messages that best affect these varying influences, which, ultimately, will affect prescribing.

This new paradigm requires companies to understand the nuances of influence at every level—from what affects doctors' prescribing habits to which physician is most influential in an office. There are certain benefits inherent in this approach:

• It shifts the focus from quantity to quality.

• It necessitates a better understanding of the target audience, going beyond a solely decile-defined value to a broader, more sophisticated profile.

• It calls for a holistic, integrated approach so reps can understand and speak about the context of these market influences, to help physicians manage in this more complex environment.

• It creates real value for physicians.

• It demands flexibility and rapid response to changing market conditions to better serve healthcare providers.

Share of influence affects every aspect of sales-force infrastructure—recruiting, training, sales operations, and performance management. While no silver bullet exists to rapidly identify and implement the sales-force model of the future, the new share-of-influence approach has certain implications that affect how companies should define any new model. Here, we offer five strategic and tactical implications of the influence model, and some ideas about how to deploy and organize the sales infrastructure around it.

Five Tips for Growing Sales

(1) Use influence mapping to define target audiences

Influence mapping is one key to unlocking the share-of-influence paradigm. It is a sophisticated approach to physician targeting that goes beyond understanding the number of prescriptions physicians write, and instead examines the complicated and interrelated influences within the peer-to-peer medical community at the local level. It zeros in on why high-level influencers have prescribing preferences, and how those preferences are translated along that intricate web of relationships. By looking at the market this way, companies can more efficiently allocate sales and marketing resources because they can direct their efforts toward those influences that have the most impact on actual prescribing and dispensing behaviors.

Local influencers have an impact on sales and market share far beyond their individual prescribing behavior. They can include:

• established and well-regarded regional and local thought leaders

• community specialists (who garner the lion's share of referrals in their specialties, but whose patients eventually return to the primary-care referrer)

• group-practice thought leaders (who influence the prescribing of the entire group)

• academic and attending physicians (who influence residents by training them, thereby creating prescribing habits).

By way of example, let's take a closer look at community specialists, such as cardiologists. Most often, the specialist initiates the therapy and then directs the primary-care physician (PCP) to maintain that therapy in follow-up. In the traditional share-of-voice approach, companies would target the PCP because, given the number of refills, it may appear that the PCP's decile is higher in a given category and product. This approach devalues the cardiologist, who is writing scripts that are then being renewed by a PCP. But in fact, the cardiologist is the primary influencer—the PCP typically does not change the therapy prescribed without direction from the specialist.

For the most part, companies already identify and communicate with national and regional thought leaders—an activity that is at the core of medical education efforts. By educating "tier-one" and "tier-two" thought leaders, companies know that they are affecting physicians who have a dramatic impact on influencing their peers. But as the medical community's peer-influence relationships bear significant influence on a physician's prescribing behavior, it will be increasingly important to take a local view (see "Group Dynamics").

(2) Use integrated hybrid communications

Once companies understand how influence works, they need to plan out how to deliver their messages to best leverage it. In the share-of-voice world, outreach was characterized by inefficiencies, mostly born from silos separating sales and marketing. The silo approach results in duplication of efforts, communication gaps, lack of coordination, inefficient coordination between functional areas, and economic inefficiency. In effect, it keeps reps and other key stakeholders in the dark.

To that end, companies should move to using integrated hybrid communications so that all tactics work together to leverage the appropriate influences. In doing so, companies can formulate strategies that move the needle, instead of just making more noise.

For example, in the share-of-influence world, companies that face strong managed-care influence in a geographic area will layer prescriber-level prescription data on local managed care formularies into strategic decisions, targeting efforts, sales training, and sales messages. In doing so, companies can leverage a brand that has a favorable position on a formulary in a region that is heavily influenced by managed markets, to gain more prescribing in patients on that formulary—and to effect a positive spillover to that doctor's other patients who may not have those formulary restrictions. On the other hand, if that same product has an unfavorable formulary position, reps can then influence that physician by focusing on the patients in his or her practice who are not impacted by this particular formulary, to maximize prescribing.

Another example shows the importance of leveraging outside influences. Let's say an important study is published in a prestigious journal on a particular brand a rep is detailing. In the influence model, reps should understand the importance a particular clinical study may have, analyze how that study may be of interest to an individual physician, and then communicate that information in a way that shows the rep understands the general implications of the study—as well as the implications for that specific physician.

New types of technology will enable this integrated approach. Currently, companies measure sales activity and provide data on targeting and sales performance, but fall short of linking available information from other sources and offering it to reps. For example, if the marketing department conducts direct-mail and telemarketing initiatives, and a different functional group is conducting a series of regional promotional events, that information is not necessarily easily available to the field in any kind of holistic or integrated way. Instead, reps should be able to access, in a central location, company-generated influences that have affected a given physician—such as noting a physician's response via a business reply card to a direct-mail campaign, the physician's e-detailing activity, or a particular provider's telemarketing activity and response. This type of closed-loop marketing creates a more customer-centric approach that provides better influencer-level insight by connecting each resource, providing direction and metrics, and continually re-evaluating key influences and ROI.

This allows companies to mix and match their selling efforts with reps and other types of non-personal efforts by identifying the particulars of influence on a given prescriber and allocating resources accordingly. It also allows for a better analysis of impressionable sales—how much impact can be had on a given physician's prescribing—by varying the level of resources based on the degree of influence. For example, companies can experiment with service and tele-reps with lower-volume prescribers, who otherwise may have minimal or no sales-rep coverage, or support sales-force efforts with high- and intermediate-level prescribers.

(3) Create real value for physicians

Of course, when it comes down to leveraging influence, companies must invest where the rubber meets the road: their sales reps. While information on key influences (and direction on how to best communicate with prescribers based on those influences) will certainly continue to reflect significant corporate input, companies need high-level, exceedingly well-trained sales reps to analyze and interpret the information, to educate physicians with messages tailored to the changing influences, and to engage providers in meaningful dialogs. In that spirit, one common element in any model under the share-of-influence sales approach is a return to creating real value for physicians.

Strong first-line management will provide the foundation for this increased focus on customer value by measuring performance-based metrics (such as market share) and the value-driven methods to get there, instead of activity-based measures (such as reach, frequency, and calls per day).

But in order to get there, companies will have to redefine the profile of the field force. The share-of-influence model puts forth a much more complex world that requires better interpretive and communication skills from sales reps.

Reps in the share-of-influence world don't deliver a consistent standard sales message to everyone. Rather, they work to generate a discussion with the physician about his or her practice, patients, and prescribing, and about how the product may help better manage patients. The sell, then, is geared specifically to that physician's practice.

The level and competence of the new "standard" rep will have a higher skill set and stronger relationships with providers than today's typical mirrored PCP rep. Companies will hire reps with more credentials (for example, former nurses, or pharmacists), reps with more science and/or medical training (such as ones with Master's degrees in biology, for example), and reps with significant experience in pharmaceutical sales. Individual profiles may vary, but at minimum, reps must be able to easily understand and communicate the intricacies of a high-science product, market, and disease state.

To deliver this type of rep, companies must emphasize long-term training and development. While companies now update reps over time about product and medical information, like changes in labeling and in practice guidelines, the share-of-influence approach expands that training to help reps better understand the constantly changing influences. This is especially important in providing value as the Medicare drug benefit goes into effect.

Specialization is a growing trend not only in medicine, but in pharma sales as well. Pharma companies are beginning to use specialty reps to reach primary-care physicians who perform a specialist role, such as in urban or rural areas that lack specialty physicians.

Increasingly, the industry is using another type of specialized field rep: the service rep. Service reps do not concentrate on detailing physicians, but rather, on supporting healthcare professionals and their offices with samples and patient-education materials. The service rep frees up the sales rep, who is focused exclusively on education and dialog with the physician and staff, from duties that are important, but that take up a significant amount of time and can be done by a rep with less medical or science background—and at a lower pay scale.

(4) Use strategic outsourcing for competitive advantage

Today, Big Pharma companies use outsourcing to become nimble, quick organizations that can effectively respond to changing market conditions with minimal disruption to their organizations. Emerging pharma companies use outsourcing partnerships to achieve commercialization and to maximize profitability and control. In the share-of-influence model, companies will continue to outsource, as responding quickly and with relative ease to changing market influences becomes more important.

In fact, the industry as a whole may find that it increases the use of strategic outsourcing as certain tools—such as patient-level data and quarterly retargeting—become a reality and call for changing activities to most effectively influence key physicians. For example, under the share-of-influence approach, a company may want to quickly deploy a supplemental sales force to communicate about a major new clinical finding, or to respond to specific changes in managed markets, in order to gain a competitive advantage. In that way, companies can respond to these types of shifts in key market influences without disrupting their core infrastructure and without taking on the significant risk of using critical company resources to permanently hire in-house.

Companies that have moved toward the influence model are also beginning to outsource functional areas that almost certainly would have been handled internally just a few years ago, such as medical science liaisons (MSLs).

Some reasons companies are increasingly outsourcing include:

• adaptive experiments of pilot initiatives—testing various selling approaches, either nationally or regionally

• expanding to influence markets outside of a company's core competency—for example, a primary-care company outsourcing a specialty sales force

• rapid response to a new or emerging market influence—such as using an outsourced sales force to augment the efforts of the company's primary sales force during a launch

• influences with a short-lived impact—such as a sales-force effort based on competitive activity or seasonal impact.

(5) Individualize your sales force

While each company's new sales model will share a number of similar characteristics, moving to the share-of-influence approach marks the end of the one-size-fits-all model. Indeed, what's best for Pfizer might not be best for your company. Instead, individuation will be a key characteristic of new sales forces, liberating companies to bring rationalization to their approaches. Influences driving the specifics of a sales force's blueprint include:

• the impact of managed markets

• geographic considerations

• the company's pipeline and existing product line

• the relevant disease states and specialty audiences

• competitive landscape

• other market factors that influence prescribing and dispensing.

Companies must also look within therapeutic franchises to orchestrate the optimal sales deployment for each product, depending on the relevant influencers. In particular, companies are increasingly using SWAT (strategic work assignment teams) reps who address the needs of specific ethnic markets, managed markets, and urban initiatives that focus on influences unique to a given geographic area. They often deal with issues that a national strategy simply cannot. For example, a small emerging-biotech company may find that its sales model includes MSLs, high-level sales reps, and SWAT reps for high-population areas that most dramatically affect its business. In that way, just as modern medicine is focusing on more targeted therapies that affect particular receptor sites—oncology, for example—pharma sales is allocating promotional efforts in a more targeted, precise, and tailored way.

Invent the Future

Pharmaceutical companies have the tools, talent, and energy to evolve and prosper in this changing, challenging environment. Many already are methodically deconstructing the traditional sales model as they experiment with, test, and revise new sales paradigms for optimum success.

The evolution that is occurring in this new share-of-influence world is a major paradigm shift that affects every area of the pharma industry. There are no easy answers. Fully evolving to this brave new world will take some time as we map the influences, prioritize the impact, respond with innovative initiatives and selling models, measure and test those initiatives, allocate resources accordingly, and continually improve the process based on ROI—efficiency, effectiveness, and better serving customers.

We can succeed in the new, evolving share-of-influence world. To do so, however, requires active acceptance of the changing marketplace—by inventing our own future. Companies that are embracing the new share-of-influence world are those that are aggressively employing adaptive experiments of various sales models to measure and evaluate the sales-force blueprints that best fit their needs based on the influences affecting their markets.

Group Dynamics Group physician practices are growing in both size and number within the United States. The number of doctors in physician groups of 100 or more, more than doubled in the past 10 years. The number of doctors in physician groups of 15 to 49 has increased almost 90 percent since 1988. This trend showcases the importance of local influence mapping because group practices increase the complexity and importance of interrelationships, and the sheer number of doctors who are influenced by group-practice dynamics.

Source: Health Strategies Group

The world of managed care is helping to usher in the share-of-influence approach. For physicians, managed-healthcare markets are generating the need for more paperwork, more staff, and more administrative costs—all the while reducing revenue for physicians. New pharma reps recognize this in the following ways:

»They have a clear and full understanding of the market they work in and the influences affecting the physicians they see.

» They help physicians and their staff navigate formulary restrictions, tiered co-pay structures, and prior-authorization requirements.

»They understand the type of information physicians want—clinical studies, evidence-based medical protocols, or educational opportunities—and are experts in providing it, allowing physicians to better manage their patients' health. »They are well connected to local thought leaders and related specialists, and therefore can facilitate sharing of this information in their medical communities.

» They stay up-to-date on current events that affect physicians and their patients—such as HIPAA and Medicare Part D—and can articulate the impact to their customers.

»They forge strong, lasting relationships with their customers based on trust and respect.

Mike Iafolla is chairman, and Steve Greco is president of Publicis Selling Solutions. They can be reached at miafolla@psellingsolutions.com and sgreco@psellingsolutions.com respectively.