Friday, April 11, 2003
The Florida Times-Union
By Sarah Skidmore Times-Union business writer

The well-groomed, suitcase-toting salesman squeezed into the chair next to you in the doctor's waiting room isn't sick, but he wants to see the doctor as much as you do. So much so that he might pay for his visit too.

The growing number of pharmaceutical sales representatives -- an estimated one for every 4.7 physicians -- are each competing for doctors' increasingly limited time. Face-to-face sales calls are the primary function of their job, but under a new service being offered by a Jacksonville-based startup Medical Partners, reps may now pay for access.

The physician visit is one of the most popular marketing tools in medicine and is a multibillion-dollar marketing expense for the behemoth pharmaceutical industry. During the visit, sales reps detail the benefits of their product by offering new information, samples, research or by simply answering doctors' questions with the hope of swaying prescribing habits in their company's favor.

But the borders of the industry standards are changing, and now the business tactics are following.

"Up until five or six years ago [reps] had carte blanche with doctors," said Sam Hinson, a former pharmaceutical rep and director of business development for Medical Partners. "They had an unlimited expense account for doctors and open access to meet with them. Then most of the seats [in the waiting room] were taken up by sales reps rather than patients, so a lot [of practices] limited, restricted or eliminated it completely."

The company launched in November of 2002 to help physicians manage the growing number of pharmaceutical representatives trying to get in the door: There are more than double the number of reps in 2001 than in 1996.

Medical Partners is not the first company to use fees as a management tool for representative visits. The Polyclinic, a busy Seattle medical practice, charges reps $30 for one hour's access; and for $200, reps get eight hours but no guarantee of time with a physician. Queen's City Physicians in Cincinnati created a subsidiary, Physician's Access, to charge drug companies $65 for a 10-minute meeting. And Time-Concepts, a Crestview, Ky., company gives physicians a $50 payment for a 10-minute visit.

In response to the volume of visitors, some physicians and clinics limit the number or type of visit, but a handful charge directly for their time used by a rep or have companies like Medical Partners do it for them.

For a fee, the company schedules everything from the staple five-minute, face-to-face meetings with the doctor to occasional symposiums or programs involving multiple physicians. Physicians contract with the company and agree only to see reps scheduled by Medical Partners. Reps who want to see physicians log in online, set up their appointment and pay a fee. For a five-minute time slot, the rep pays $35; $20 of this goes to the physician. Physicians can keep the money or choose for it to go to a charity or other group. Physicians agree to make their best effort to meet with the rep in a timely matter.  This new twist on the relationship between pharmaceutical companies and physicians puts doctors in the spotlight typically reserved for the drug companies.

The pharmaceutical industry's infamous perks -- a lunch, a pen, any tchotchke left behind to separate their name from the pack -- are standard practice. But in the past few years when this tactic appeared to become occasionally excessive, the American Medical Association and pharmaceutical trade group PhRMA clarified guidelines and launched an educational campaign on acceptable relationships between physicians and reps.

AMA has had long-standing recommendations to avoid pharmaceutical industry influence on medicine but launched its efforts as a reminder of the importance of the guidelines. According to the AMA it became clear that exorbitant gifts, trips and other perks were becoming more commonplace, and the association wanted to avoid any possible conflicts of interest. PhRMA endorsed the recommendations for its members as well.

Guidelines recommend physicians only accept gifts or other services or goods of modest value and only if they relate to the practice and have no strings attached.

But when it comes to actual payment for visits, the American Medical Association guidelines prohibit cash payments. And in all the gray areas of pharmaceutical influence, this issue remains a clear black and white one to Leonard Morse, chair of the Council on Ethical and Judicial Affairs for the AMA. "Genuine services receive compensation, but in this situation it is the rep who offers the service, namely the education of the physician," said Leonard Morse. "Doctors are not compensated for education."

The several pharmaceutical companies contacted stood behind PhRMA's position but declined to comment directly. But several reps said their companies will not reimburse them if they use services such as Medical Partners.  "Sales representatives are technically trained, and it is not only a chance for a sales pitch, it's a chance for asking technical questions," said Jeff Trewhitt, spokesman for PhRMA. "Doctors should want to getthis information."

But some doctors argue the educational information is a ruse for marketing in most cases.

"I do not get my medical education from a pharmaceutical rep that has an accounting degree, they do not have a Ph.D. in pharmacology, they do not have a medical degree," said Oscar Rodas, a Jacksonville internal medicine physician. "I don't rely on them for my education."

He said in most cases the meetings are primarily giving the reps a chance to market their products, but he does not see a conflict of interest in these arrangements.

"At least with the physicians I know, none of us have ever been influenced by something a drug company does in our prescribing habits. ... Ultimately, we make our decision based on how a patient will react to a treatment, and we are responsible for that," Rodas said.

His clinic has tried for years to schedule reps with some success, but it still has anywhere from eight to 10 reps drop in each day, which is an interruption to business. Rodas said he has been approached by several groups for this arrangement and is likely to sign up with Medical Partners because he feels the arrangement compensates for the time he spends with reps.

Medical Partners said it intentionally kept the fee lower so financial gain would not be an incentive for physicians. However, by charging a fee, the company said there may be more respect for the importance of the meeting.

As a former rep himself, Hinson said much of the educational and drug efficacy information that can be given in a visit is often overlooked because the benefit of a rep visit is outweighed by the resulting disruption to the office. The professional interaction has been lost when reps spend hours waiting to talk to a physician or only drop off samples but he hopes his company can help rebuild the benefit of the relationship.

"Once they see the value in it -- they'll embrace it. I'm confident in that," Hinson said.

Pharmaceutical reps contacted were prohibited by company policy to speak with the Times-Union.

Medical Partners is running its trial program now. The company has signed up 10 to 12 physicians so far and it will be ready to start its program at the beginning of May with 40 physicians.

Following the trial here, the company hopes to expand in Florida.

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