With the Physician Payment Sunshine Act in full effect, the challenges that pharmaceutical sales representatives will face accessing physicians and other prescribers will only continue to grow as many practices, institutions and hospitals begin to update and change their policies in light of the increased transparency.
Consequently, a number of recent articles have highlighted the challenges sales reps are facing and some of the solutions and options companies have created to address these roadblocks.
For example, a new study from CMI/Compas found that half of physicians restrict visits from reps in one way or another. And the doctors reps want to see most—including oncologists and internists—are least likely to prefer a human face over other kinds of communication. In another recent study, ZS Associates found that almost 45% of prescribers restrict sales reps access—which is almost twice as large a share as the 23% who restricted access to their practices in 2008.
The ZS report incorporates sales-call reports from more than 200 different U.S. pharmaceutical sales teams. The report examines how often approximately 325,000 physicians and other prescribers meet with pharmaceutical sales representatives who visit them.
FiercePharma, which reported on both studies, noted that there is some good news for reps. For instance, the CMI/Compas study found that doctors do want information from drugmakers, whether from reps, or through e-detailing, email, direct mail and the like. And when it comes to information on brand-new drugs, doctors--even some oncologists--do like to talk with reps. Half of cancer docs said they'd chat about new products with reps, while 47% of them flagged email as a preference.
However, the survey showed that oncologists are the "most restrictive specialists, with only 19% allowing reps in the door without restrictions." On the other side of the coin, 20% won't see reps at all, with the 40% in the middle either requiring appointments or limiting visits to particular hours of the day or week. The ZS Associates report found similar results with almost two-thirds (65%) of oncologists having "moderate to severe" rules governing rep visits. "[E]ven the best reps visit oncologists just once per month," ZS principal Ganesh Vedarajan said in a statement, with average reps managing to get in the door 7-8 times a year.
This is a drastic increase from 2008, when only 17% of oncologists restrict access to reps. "Access has continued to decline due to an increased number of oncology reps trying to reach the doctors and an increasing number of doctors joining institutions that severely restrict rep access."
Access by sales reps is also most restricted in areas with major cancer centers. For example, the MD Anderson Cancer Center, Mayo Clinic and Dana-Farber Cancer Institute are all located in metro areas that fall in the bottom 20 percent in terms of access to oncologists.
"Access has historically been challenging in academic institutions, so it's no surprise these places remain restrictive," said Vedarajan. "However, in recent years, we've seen a similar decrease in access to large group practices as they attempt to improve efficiencies and streamline their business models. In the same vein, parts of Texas, Georgia and Florida also have high access restrictions."
Accordingly, sales reps need other alternatives, particularly for oncologists, who said preferable alternatives include email, direct mail, and peer-to-peer programs. Alternatives are critical as companies continue to make high-profile targeted cancer drugs, particularly with the new pathways FDA has recently adopted and the patient-centered focus the agency will continue to adopt over the next few years.
The ZS Associates report did find that oncologists were more likely to open their doors "for reps with new drugs to offer," (33% more frequently) but such kindness closes "quickly—after about 6 months." "New information on existing drugs, such as new clinical trial data, helps as well, [w]hich means companies might want to consider their publication schedules accordingly, ZS says."
In addition, oncology reps with three or more products are able to visit physicians an average of 10 times per year. But those carrying just one or two products only see physicians an average of seven times per year. On average, a rep carrying three or more products is twice as likely to have access to even the most restrictive oncologists (26 percent vs. 13 percent for reps carrying one or two products).
Primary care doctors put fewer restrictions on the reps they'll admit, but they're less accessible overall—with 24% of family practitioners and pediatricians barring the door, along with 21% of internists. And internists are most likely to prefer other types of detailing; 78% of them say they'd prefer fax, mail, email and so on, and only 67% like in-person visits.
Endocrinologists, urologists, neurologists and cardiologists were least likely to keep reps out of their offices, and more likely to say they like to meet with sales folks. In fact, 86% of urologists said they like to get info from reps, compared with 38% who like other forms of communication.
The ZS Associates report found that about 58% of cardiologists and 47% of primary care physicians restrict rep access to the same degree.
Regardless of the access to physicians, ZS Associates noted that companies "need to rethink their sales strategies overall." Sales reps should tightly focus on what doctors need, "whether knowledge or reimbursement support or clinical trial enrollment assistance." In addition, sales reps need to realize that physicians (of all kinds) prefer short vists. The CMI survey showed that 85% of HCPs polled said the ideal "visit" was five (5) minutes or less, with many favoring the five-minute web conference (43%), e-detail (79%) and in-person visit (50%).
Conversely, CMI's survey showed that physicians had a very limited tolerance for visits lasting up to 15 minutes, with a precipitous drop once things move into the 16-minute plus category. "In short, reps should not waste time banking on a 16+ minute phone call, whereas there was more willingness (16% of polled HCPs) for web conferences. As for a leisurely 30-minute conversation, forget it. Zero to 2% of polled doctors favored a 30-minute phone call, web conference, e-detail and in-person visit," reported Medical Marketing & Media.
"The traditional way of physicians interacting with the sales force is not working--it's not as effective as in prior years," ZS Managing Principal Pratap Khedkar says in the AccessMonitor report. "When half of your customers don't want to interact with you the way you want to interact with them, it's a problem." The ZS reported noted that companies can focus on three areas to improve access, while also taking into consideration "practice setting, geography and" the type of diseases they treat.
First, companies must rethink their approach to academic institutions and large practices. "The traditional one-to-one selling is no longer sufficient and companies are piloting different account management models to increase the customization and relevance to a large customer," said Jon Roffman, associate principal with ZS Associates.
Second, pharmaceutical companies must customize the portfolio of products that each sales rep carries to become more customer-focused. For example, some companies have evolved their product-focused sales teams to become more tumor-focused. This enables reps to tailor their offerings to particular treatment areas of interest to each oncologist.
Third, to maintain long-term access and relevance to oncologists, companies must develop new, innovative customer engagement models – designed not from the perspective of the pharmaceutical company, but from the perspective of the customer. The trend is toward improving the sales process to optimize customer experience
A study last year in the Journal of Clinical Hypertension examined how physicians' offices who fail to see reps, are less likely to react to FDA black box warnings, and slower in adopting newer and better medications and doses.
New Options, Ideas for Sales Reps
In addition to these recommendations, a recent post from World of DTC Marketing.com noted that sales reps should be refining and enhancing their use of tablets (e.g. iPads and other gadgets) with physicians during details and meetings. The post notes that tablets "clearly enhance details, lengthening rep visits and piquing physician interest in follow-ups, and 54% of ePharma Physicians agree that they make meetings more valuable. But getting the most out of tablets requires understanding where they're most valuable."
The post notes that "animations and videos [are] where tablets shine – particularly when they're being used to facilitate "Ah-hah!" moments by, say, illustrating a novel MOA or treatment pathway."
"Physicians expect to be wowed, and where tablets are merely replacing printed materials, content must be crisp, with intuitive navigation, responsive design, and attention to basics like appropriate fonts and the distance from eye to screen. And it's not all about tablets."
Accordingly, the post notes that physicians handling tablets in meetings will make them "more likely to spend more time with the rep, to research further information online, to request samples, and to pre- scribe the drug discussed."
Another option, recently employed by drug-giant Pfizer, is the use of "digital" sales reps through Skype. According to an article from Pharmafile, Pfizer has been promoting a new service in the U.K. called "Pfizerline," which allows primary care doctors to book time with reps. Ads in the BMJ (formerly the British Medical Journal) tout the convenience of anytime, anywhere contact with Pfizer reps bearing info about the company's products. The service also offers links to product information about branded medicines available in the U.K.
FiercePharma, which covered this new service, noted that Merck has previously spent "heavily" on e-detailing, and other companies have "amped up" their efforts. This kind of approach might be able to resolve the lack of access reps are getting as noted in the first part of this article. Another benefit of e-detailing is it requires less staff and less resources. Ideally, a company would only need a "call center," where sales reps could be stationed to respond to e-detail calls. This would cut out the travel and associated expenses, and would decrease tremendously the risk of non-compliance with institutional or practice requirements or other compliance risks associated with sales reps.
For example, as FiercePharma notes, if "presentations are vetted ahead of time, and Skype conversations recorded, then off-label shenanigans would be more difficult to hide."
Finally, another interesting aspect that companies will have to consider is whether to detail pharmacists. Recent data suggest, as reported by MM&M, that "pharmacists may be influencing patients' drug decisions," particularly for seven over-the-counter products and five prescription drugs.
Specifically, Kantar Media's 2013 Pharmacy Readership study surveyed more than 130,000 US pharmacists. Of those, 39% of full-time pharmacists were retail staff and 30% were retail managers; 9% of those polled overall were also members of formulary committees.
On average, they made 4.8 prescription recommendations and seven OTC recommendations per day. Those numbers were slightly elevated from last year's results, which found 4.5 recommendations for prescriptions and 6.7 for OTC.
Consequently, although pharmacists recommended a generic drug 85% of the time over a branded drug (when they have the option to do so), 57% of pharmacists said their policy towards sales reps is to see "all or most" of them.