As drug bill soars, doctors get an 'unsales' pitch in PennsylvaniaTuesday, March 14, 2006By Scott Hensley, The Wall Street JournalPHILADELPHIA -- Like salespeople for pharmaceutical companies, Kristen Nocco shows up in doctors' offices with slick brochures, well-rehearsed talking points and the budget to buy lunch.
But Ms. Nocco's goal is the opposite of the company people: She wants doctors to consider alternatives to expensive brand-name drugs.
Ms. Nocco, who used to be an Eli Lilly & Co. saleswoman, is part of an "unsales" team funded by the state of Pennsylvania. Its message is honed by Harvard University professors who say they're trying to help doctors make decisions grounded in scientific evidence instead of company marketing. Many of the approaches Ms. Nocco advocates -- such as cheap generic drugs and lifestyle changes -- would cost less, too. Some of her talking points take on top-selling drugs such as AstraZeneca PLC's Nexium for heartburn and Pfizer Inc.'s Celebrex for arthritis pain.
The effort comes as states and employers are reeling from ever-higher bills for prescription drugs. Pennsylvania alone spends about $3 billion a year on drugs for state employees, poor people on Medicaid and elderly people eligible for a generous drug-assistance program.
Pharmaceutical companies go to great effort to ensure that doctors think of brand-name products when they pull out their prescription pads. While the most visible part of that effort is a barrage of television ads, companies spend more money addressing doctors directly. Makers of brand-name drugs employ more than 90,000 salespeople in the U.S. at a cost of more than $12 billion a year, according to Amundsen Group, an industry consulting firm.
These "detailers," so called because they can recite drug facts from memory, crowd into doctors' offices, handing out pens and notepads emblazoned with brand logos and hoping to corner the doctors for a minute or two to deliver a sales pitch. Companies track doctors' habits by purchasing data collected when pharmacies fill prescriptions. A company knows which doctors are friendliest toward its drugs -- and which salespeople are the most effective.
Now a wave of generic alternatives to some of the nation's best-selling drugs is sweeping into pharmacies as old patents expire. Generic copies of Merck & Co.'s blockbuster cholesterol drug Zocor will go on sale in June and could be prescribed in place of Pfizer's branded drug, Lipitor, the industry's No. 1 seller with 2005 U.S. sales of $7.4 billion. But generic companies don't have huge sales forces behind their products.
That's one reason some organizations are fielding their own representatives to make sure the new generics and other alternatives to brand-name drugs are getting used. At Kaiser Permanente, the big California health-maintenance organization, one part of a broad doctor-education program looks for doctors who seem to be overprescribing or underprescribing certain pills. Kaiser then sends pharmacists or senior doctors to advise these outliers.
Medco Health Solutions Inc., which manages drug benefits for large employers, sends pharmacists to encourage doctors to use generics. Governments in Australia, Canada and the United Kingdom also seek to educate doctors in their own offices.
Ken Johnson, a spokesman for the drug trade group PhRMA, said in a statement that the industry encourages doctors to study a variety of information. But he said "it would be a big mistake to discount or ignore information provided by sales representatives who work for the companies that spend 10 to 15 years developing each new drug." Companies "have the most information about new treatments," he said.
At Harvard, Jerry Avorn, a professor of medicine, has been a pioneer in what is called "academic detailing." He says the goal is to use industry sales techniques -- such as boiling down material to a few bullet points -- to deliver a message based on evidence about what works best.
Thomas Snedden, who runs the Pennsylvania Department of Aging's drug-assistance program, called on Dr. Avorn when he wanted to counterbalance brand-name marketing. The department, via a contractor, agreed to pay a foundation led by Dr. Avorn $3 million over three years to put an "unsales" force in the field.
Pennsylvania has long tried to influence prescribing by doctors in the state. In the early 1990s, Mr. Snedden's department took advantage of computerized ordering systems at pharmacies to block state payments for Halcion, a sleeping pill then linked to violent agitation especially in the elderly. Worried that doctors were ignoring heightened warnings, the state started rejecting prescription claims for Halcion. Prescriptions dropped 95 percent in a month, Mr. Snedden says.
Mr. Snedden acknowledges that overriding prescriptions at the pharmacy isn't popular with doctors or patients. "We're trying to go directly to the physicians, instead of the pharmacists, and have a dialogue with them about prescribing practices that we think should be corrected," he says.
That's where Ms. Nocco, a 37-year-old pharmacist, and her seven colleagues come in. Their goal is to get busy doctors to set aside time to hear a presentation. Since September, the Pennsylvania unsales representatives have made contact with doctors about 1,500 times and conducted more than 400 educational meetings.
One morning, Ms. Nocco walked into a doctor's office in the Olney neighborhood of North Philadelphia. Like drug companies, Dr. Avorn's organization had done its research and knew the doctor was a heavy prescriber of drugs to the elderly. Ms. Nocco found a waiting room packed with patients. Two drug-company representatives stood between her and the receptionist's desk. She turned on her heels and hustled back to the parking lot, figuring she might have better luck at the next office on her list.
"Having failed so many times, it doesn't bother me anymore," she said. She was in a hurry to squeeze in one more appointment before a lunch meeting nearby that took weeks to set up.
In the beige Mazda minivan that doubles as family taxi and mobile office, Ms. Nocco pulled out a sheaf of maps and driving directions she had printed from the Internet. She lives in Philadelphia's Center City with her husband and two children and is still learning her way to the 75 doctors in her territory.
Twenty minutes later, she arrived at the next stop and lucked out. The doctor overheard her explaining the program to his receptionist, put aside a patient's file and invited Ms. Nocco inside for a two-minute chat. He asked her to call later to schedule a longer appointment.
Though Ms. Nocco believes she carries a more enlightened message than her corporate counterparts, she faces the same barriers to getting in the door. "Until you prove yourself, they're going to treat you like a drug rep because you are," she says. "You're asking for the same thing: their time."
Unlike company representatives, she doesn't have any coffee mugs, clipboards or other logo-festooned items to give to doctors or their staff. To break the ice, she uses her one advantage: her link to Harvard and Dr. Avorn. She carries a letter of introduction from the professor and tells doctors they can have a free copy of his book on the drug industry if they listen to her spiel. Or they can choose from two general-interest medical books by Harvard doctors.
Also, Harvard has certified the content of her talks and brochures as educational. Doctors who listen to the material and pass a short quiz receive continuing-medical-education credits, which many of them need to maintain their professional certification.
Dr. Avorn is confident his team can get traction despite being outnumbered. "Doctors know when they're being sold a bill of goods, and they know when they're getting the straight scoop with no hidden agenda," he says. "They crave the latter, and they know they hardly ever get it."
Mr. Johnson of the drug-industry trade group said company representatives are well-trained to answer doctors' questions about proper use of drugs and noted that they must comply with strict federal regulations on what they can say.
Ms. Nocco aims to sit down four times a year for 15 minutes or longer with the doctors she has been assigned. All told, the unsales representatives are targeting about 1,000 doctors of the 26,000 across the state. For now, they are being judged by how many meetings they get with doctors. Mr. Snedden says it's too soon to detect any impact of the unsales program in Pennsylvania, but "ultimately, we need to see a change in the prescribing patterns."
Just before noon, Ms. Nocco arrived at the office of a group of geriatricians on the campus of Jeanes Hospital in the leafy Fox Chase district. In the lunchroom under a purple wall clock bearing the logo of AstraZeneca's Nexium, the heartburn pill, she unwrapped a tray of Italian hoagies delivered by a shop she discovered in South Philadelphia when she worked for Eli Lilly.
She left the drug maker in 1998 to go into advertising, specializing in prescription drugs at a small agency in Philadelphia. After leaving the agency because of family responsibilities, she worked on another academic detailing project that led to her current job in the Pennsylvania program.
Over lunch, she told three doctors about the program and joked, "I'm redeeming myself now" after years working for the drug industry.
Her subject was managing pain without Merck's Vioxx and Pfizer's Bextra, two drugs that were withdrawn from the market over safety worries. Pfizer still sells a similar drug, Celebrex, which costs about $80 for a month's supply. Ms. Nocco suggested over-the-counter alternatives such as naproxen or acetaminophen, which is best known by the brand name Tylenol. The drugs cost less than $9 a month, she said. If they don't work, she suggested prescription alternatives, including some generics. She went on to discuss a variety of options for severe pain.
After almost an hour, Martin Leicht got up to leave. "This was much more fun than a drug-rep lunch," Dr. Leicht said. "They won't come in and say, 'Use Tylenol first.' "
Recently Ms. Nocco and her colleagues have been targeting overuse of costly heartburn pills called proton-pump inhibitors. These drugs, which include Nexium, can cost more than $100 a month. Patients need to take them every day.
The unsales representatives say many people can find relief by watching what they eat or taking inexpensive over-the-counter medicines such as antacids and Zantac. If neither of those remedies works, patients can try a proton-pump inhibitor -- perhaps starting with Prilosec, a chemical cousin of Nexium that is available more cheaply over the counter. Prilosec or Nexium may only be needed for a few weeks before patients are weaned off, according to the unsales pitch.
Cynthia Callaghan, a spokeswoman for AstraZeneca, says in an email that the older drugs may be appropriate for some people but she says clinical-trial data show Nexium offers superior relief. Sales of Nexium, AstraZeneca's biggest product, increased 18 percent to $4.63 billion last year.
Nexium alone accounted for more than $15.2 million, or 2.8 percent, of total drug spending by Pennsylvania's elderly assistance program last year, or 15 times the annual budget for the unsales representatives. William Trombetta, professor of pharmaceutical marketing at St. Joseph's University in Philadelphia, says: "Given the price of Nexium, it would not take much in terms of switches to more than cover the state's detailing cost and then some."
