The Devil's In The Detail (Men) Part One

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Monthly Newsletter | www.CancerCoverup.com | October 2004

 

The Devil's In The Detail (Men) Part One

 

 

 

BY KATHLEEN B. DEOUL

 

Most Americans are painfully aware of the fact that health care costs

are spiraling out of control. Many even understand that the exorbitant

cost of prescription drugs is a major factor in the runaway inflation

that has afflicted healthcare spending. Few, however, are aware of the

role that pharmaceutical sales representatives - called " detail men "

in the industry - have played in this growing crisis.

 

PILL PUSHERS

 

Even a cursory examination of healthcare spending makes it evident

that the current generation of doctors has been convinced that there's

a pill for everything that ails you - and even for some things that don't!

 

U.S. sales of branded pharmaceuticals rose from $12 billion in 1980 to

$58 billion in 1990 and $116 billion in 2000. According to the

Department of Health and Human Services, Americans spent $162 on

prescription drugs in 2002, an 11.3% increase from the previous year -

at a time when inflation was virtually nonexistent!

 

In fact, half of all Americans are now taking at least one

prescription drug and 7% are taking FIVE such medications. For seniors

the numbers are even more stunning. Fully 94% of all people 65 and

older are taking at least one prescription drug and 23% take at least

FIVE! Among women over 65 12% or almost one in eight are taking TEN or

more prescription drugs!

 

But who are these " detail men " (and increasingly women) who are behind

the tidal wave of pills that threatens to overwhelm our healthcare system?

 

THE DETAIL MAN'S ROOTS

 

Detail Men have actually been around a lot longer than you might

think. The predecessors of today's " detail men " appeared on the scene

around 1850, peddling " proprietary " or " patent medicines " to

pharmacies, general stores and even post offices as well as

door-to-door. These magic " elixirs " included such fancifully named

products as " Lydia Pinkham's Vegetable Compound, " " Dr. Kilmer's

Swamproot Kidney Liver Bladder Cure, " and " Hall's Catarrh Cure. " It

was these names that gave rise to the characterization of patent

medicine peddlers as " snake oil salesmen, " an ingredient that the

medicines sometimes claimed to contain.

 

The concoctions were most notable for two facts. First they all made

extravagant claims about their curative powers. Secondly, rather than

containing snake oil, most were heavily laced with some type of

intoxicant. Alcohol was the favorite, but opium, cocaine and morphine

were used as well. It's small wonder that people felt better after

taking them!

 

This is not to say that none of them had any therapeutic value. For

example, " Lydia Pinkham's Vegetable Compound, " which was marketed to

treat " the female complaint " was actually a suspension of the

medicinal herb Black Cohosh in alcohol. Black Cohosh is widely

recognized as an effective remedy for symptoms associated with

menopause and is currently being studied in a clinical trial at the

National Institute of Health's National Center for Complementary and

Alternative Medicine.

 

Of course, the fact that the root was dissolved in a solution that was

20% alcohol - an amount roughly equal to the alcohol content of Port

wine - didn't hurt its popularity.

 

Pinkham eventually became a celebrity of sorts. She encouraged her

customers to write her for advice and developed a wide following for

her feminist viewpoint. Many of her correspondents, however, were

shocked to discover in 1905 that she had died 22 years earlier. It

turned out that the company employed a small army of women to answer

correspondence from carefully crafted form letters that advised them

to solve their problem by taking more of the product!

 

Even in the 19th Century, these predecessors of Big Pharma knew the

value of advertising. One of the most successful was Frank J. Cheney,

who owned the Cheney Medicine Company, manufacturer of " Hall's Catarrh

Cure. " Cheney mailed two hundred thousand circulars promoting his

product daily. He was also instrumental in formation of the

" Proprietary Medicine Association, " the predecessor of today's

pharmaceutical industry lobby and a powerful political force in its

heyday.

 

An astute businessman, Cheney didn't limit his advertising to circulars.

 

By his own estimate, he spent more than $20 million annually on

advertising in between 15,000 and 16,000 newspapers. This amounted to

almost $1500 for every newspaper he had a contract with. That comes to

more than $28,000 per paper in today's dollars!

 

While being such a prominent advertiser would certainly have given

Cheney clout with the press, he made sure he had a little insurance.

He insisted that his advertising contracts included a so-called

" silence clause " that stated

 

" It is mutually agreed that this contract shall be null and void

if any law is enacted by your State restricting or prohibiting the

manufacture or sale of proprietary medicines. "

 

Seeing a good thing, all of the other major patent medicine

manufacturers belonging to the Proprietary Medicine Association (and

that was virtually all of them) followed his lead - effectively

silencing the press who were not about to publish anything in their

pages that could result in legislative action that could knock them

off the gravy train!

 

Remember, patent medicine sales were BIG business in the 1800's. In

today's dollars, their sales at the turn of the century would be

roughly $1.5 billion and contemporary estimates indicated that as much

as one-third of that revenue was spent on advertising!

 

Eventually, however their greed and contempt for the truth caught up

with them.

 

In October of 1905 Colliers Magazine began a series of ten articles

about the patent medicine business by noted muckraker Samuel Hopkins

Adams. The expose revealed the actual content of some of the most

popular nostrums, exposing the fact that most really were little more

than flavorings plus a heavy dose of alcohol or some other intoxicant.

(One of the most popular patent medicines, laudanum - sold

incidentally through the Sears and Roebuck catalog - was nothing more

than opium dissolved in alcohol.)

 

Users of Lydia Pinkham's Vegetable Compound, many of whom were also

members of the Women's Christian Temperance Union, were shocked at the

discovery that it contained alcohol. The fact that the amount it

contained was reduced from the 20% of the original formulation to 15%

by that time did little to assuage their anger. The same was true for

users of Hall's Catarrh Cure which was described in the article as " a

cheap cocktail. "

 

Following the Colliers expose, and under intense pressure from the

Woman's Christian Temperance Movement, in 1906 Congress passed the

Pure Food and Drug Act bringing the era of patent medicines to a close.

 

But the marketing lessons of that time were not lost on the modern

pharmaceutical industry. Nor was the value of the snake oil salesman

in selling products.

 

THE NEW SNAKE OIL SALESMEN

 

Like their predecessors in the 19th Century patent medicine business,

Big Pharma knows the value of advertising. In 2001 the nine largest

pharmaceutical companies - who produce the 50 drugs most often

prescribed to seniors - spent $45.5 billion on advertising but just

$19 billion on research.

 

Big Pharma also understands the importance of the personal touch!

 

Typically, the major drug manufacturers maintain a sales force of

nearly 5,000. Of these 4,000 sell to primary-care physicians - your

family doctor - and between 850 and 1,000 sell to specialists. This is

for EACH of the nine companies mind you.

 

And their numbers keep growing.

 

Between 1996 and 2001, the number of detail men more than doubled,

rising from 42,000 to 90,000. Typically a major pharmaceutical company

spends around $1 billion to maintain this army of sales personnel. In

contrast, the Agency for Healthcare Quality and Research, the arm of

the Department of Health and Human Services which oversees activities

related to increasing the safety and effectiveness of medical practice

had a budget of only $303 million for fiscal year 2003!

 

On the surface, however, it would seem that this enormous investment

was hardly likely to bring much of a return.

 

The average " detail call " costs between $100 and $150 exclusive of the

cost of any medicine samples left behind. The trouble is that a

salesman is only going to get to see the doctor about 20% of the time

- one visit out of five. That means that the actual cost of seeing the

doctor is between $500 and $750! With the cost of samples left behind

following each visit, the total cost approaches $1,000! Even then, it

would seem that the visits could hardly be productive. Almost 40% of

the time all the salesman gets to do is have a brief chat and drop off

a sample. Almost 30% of the time they don't even get to do that but,

instead are simply directed to leave their samples at the reception desk.

 

So what's the big deal?

 

Big Pharma understands something that most people don't: 70% to 80% of

all health care costs originate from a doctor's order. Whether it's a

test, a procedure or, especially a prescription, it is the doctor who

tells the patient to get it - and that really is a big deal.

 

If the decision process can be influenced, the rewards can be enormous.

 

How enormous?

 

Scott Neslin of Dartmouth College performed an analysis of some 591

drugs that each had annual revenues of at least $25 million between

1995 and 1999. The purpose of his analysis was to find out how

increased spending on different forms of marketing affected the

profitability (return on investment) of each drug. He examined the

four principal methods Big Pharma used to market its products:

detailing, direct-to-consumer advertising, medical journal advertising

and physician meetings and events. The results of the study were

stunning. For every dollar spent on detailing, the company's return on

investment increased by $1.72! That's a 72% rate of return - at a time

when interest rates are under 5%!

 

Those figures, however, were for all drugs. For the most popular items

- those with $200 million or more in annual sales, the return on

investment from detailing was almost beyond belief: $10.92! That's

roughly a 1000% rate of return. It's enough to make a Mafia loan shark

envious. In comparison, advertising in medical journals for the same

class of drugs had less than half the rate detailing did: $5.42 return

for every dollar spent, and direct-to-consumer advertising a paltry

(by these standards) $1.37.

 

But can detailing really be that effective? After all, doctors are

highly educated, intelligent and sophisticated people (if you don't

believe it just ask one)! Could they be that vulnerable to the

blandishments of modern-day snake oil salesmen?

 

The evidence suggests they are.

 

BLINDERS AND BLANDISHMENTS

 

In a classic study conducted of physicians in the Boston region,

doctors were interviewed about the way they made prescribing

decisions. Initially they were asked to rate the relative importance

of several factors that could influence their prescription choices.

The first factor they were asked to rate was their training and

experience.

 

Fair enough, doctors spend anywhere from six to eight years learning

their craft and the rest of their lives practicing it. As might be

expected some 67% said that training and experience were very

important in terms of influencing their prescribing decisions.

 

Then they were asked about medical journal articles. After all,

medical journal articles contained the latest information and doctors

supposedly read them like most people read light fiction. Again,

unsurprisingly 62% of the doctors said that medical journal articles

were very important as an influence in their prescribing decisions.

 

Finally, they were asked how important drug company advertisements and

information provided by detail men - drug company sales

representatives - were in influencing their prescribing decisions.

Here the response was quite different. The doctors interviewed all

assured the researchers that such things had at best a " minimal "

influence on their prescribing decisions. After all advertising was

self-serving, and detail men lacked the academic credentials they and

their peers possessed.

 

It was ludicrous to think that such marginally educated people could

possible have any sort of significant influence.

 

Or was it?

 

The researchers then questioned the doctors about the properties of a

number of drugs. The drugs the researchers asked about were selected

because detail men routinely made claims about them that either were

contradicted by studies published in peer-reviewed journals or at

least were unsupported by research. In the majority of the cases, the

doctors parroted the false claims of the detail men rather than the

actual data from studies and other medical research.

 

In short, the same detail men they held in such contempt were actually

the primary influence on their opinions concerning the drugs they were

prescribing.

 

For example, fully half of the doctors said that Darvon was more

potent than aspirin even though there was no evidence to support that

conclusion. In their arrogance, they couldn't admit, even to

themselves, that they had had the wool pulled over their eyes. They

simply had blinders on in regard to acknowledging the influence of Big

Pharma's blandishments.

 

This might be little more than an object lesson in humility except for

one thing: the influence of detail men on prescribing decisions is

costing all of us money - money that would otherwise be available to

lower healthcare premiums!

 

Just how bad is the problem?

 

The experience of General Motors is a useful illustration of the true

extent of the problem.

 

GENERAL MOTORS TAKES ON BIG PHARMA

 

GM self-insures its employees. As a result, the company takes care to

ensure that it knows where its health care dollars are going. In 2001,

an analysis of its prescription reimbursements uncovered the fact that

in that year alone GM had spent $52 million for the heartburn drug

Prilosec. When GM investigated, it was stunned to discover that 91% of

the patients who had been given prescriptions for the drug had no

prior history of heartburn, and had not previously been prescribed

heartburn medication.

 

How could this have happened?

 

GM blamed drug company ads. The year before Prilosec became GM's

single largest drug expense, Prilosec had set records as the most

heavily advertised drug on the market, and Astra-Zeneca detail men

were pushing it hard in doctor's offices.

 

Interestingly, GM decided to fight fire with fire. It created what

were in effect its own " detail men " and sent them out to the offices

of doctors participating in their health plan with samples of generic

heartburn drugs that were equally as effective as Prilosec urging them

to prescribe the generics instead of the expensive brand-name alternative.

 

What was the result?

 

In the first year alone, the share of generic drugs prescribed to GM

employees rose by 3% saving the company $35 million!

 

A PERVASIVE PROBLEM

 

Of course, not every company has the financial resources to do what GM

did. Moreover, Prilosec is not the only example of how Big Pharma's

detail men contribute to high health care costs. Nor is the problem

limited to the United States.

 

For example a study of British doctors found that they too were

influenced by detail men and by Big Pharma's propaganda. Specifically,

the study found a direct relationship between the extent to which a

doctor had contact with detail men and used them as a source of

educational material and their willingness to prescribe drugs produced

by that company. The study also found that doctors who had frequent

interaction with detail men were likely to be dissatisfied if they saw

a patient and were unable to write them a prescription for a drug.

 

In other words, they had been brainwashed into believing that if they

DIDN'T prescribe a drug they FAILED as a doctor!

 

Given the high prescribing rate in the United States, it would appear

that British doctors aren't the only ones who feel this way!

 

Of course, in recent years, Big Pharma has applied another basic

public relations notion to its detail force to make it more effective:

the notion that sex sells!

 

THE DETAIL (WO) MAN

 

Increasingly over the past decade, the detail man has been replaced by

the detail woman and not just any woman - a drop-dead gorgeous, movie

star beautiful woman. Big Pharma understands that a harried physician

is much more likely to take a moment to talk to a stunning young woman

than they are to disrupt their busy schedule to talk to " one of the

guys. " Numerous studies of the relationship between doctors and

pharmaceutical representatives point to the fact that establishing a

friendly rapport is an essential element in gaining the ability to

influence prescribing decisions. Protestations to the contrary

notwithstanding, it is not information, or journal articles or any

other sort of scientific data that is the primary source of influence

- it is the strength of the personal relationship a doctor has with a

sales rep. Clearly, a beautiful woman has an advantage in establishing

such a relationship.

 

Of course, the industry can't really be faulted for using sex as a

tool. Everything from automobiles to running shoes rely to some degree

on images of beautiful women to hawk their products so why not drugs?

 

The reason why is really quite simple: unlike automobiles, running

shoes or any of a thousand other products, the use of pharmaceutical

products have life and death consequences. Therefore prescribing

decisions need to be made on the basis of sound science and the best

interest of the patient, not runaway testosterone!

 

But while perhaps sordid, the use of sex as a sales tool is not the

most objectionable innovation in how Big Pharma's snake oil salesmen

(and women) are approaching their job. What is truly dangerous is the

outright corruption that has increasingly been uncovered - corruption

that not only results in inflated costs, but endangers the health of

every American.

 

Next month in Part Two of " The Devil's in the Detail (Man) " the

shocking truth about corruption in pharmaceutical sales will be revealed.