Once a symbol for the strength and might of big pharma, the U.S. sales force has undergone a dramatic shift. While drug education and brand choice were characteristic of the role of the sales representative a decade ago, they now instead play the part of account manager, and often have to work with physicians to educate them about rare diseases.
The advent of digital technologies has also shaped the way reps and doctors interact, limiting the amount of time physicians spend with reps, and changing the way they receive data.
While the role of the sales rep has been greatly diminished, the position is still an integral part of how pharma does business.
The withering pharma sales force
From primary to specialty care
Knock, Knock. No one’s home.
Say 'so long' to samples
Before we all carried mini-computers in our hands and had the wealth of internet data at our fingertips, educating doctors about products was not an easy feat. Pharma companies had to rely heavily on the sway of the pharmaceutical sales rep.
This phenomenon began in the early to mid-1990s, but the heyday of the pharma sales rep hit in the early aughts when the number of field reps in the U.S. market reached 100,000. This time of plenty was characterized by a booming economy left behind by President Bill Clinton, boy bands and the invention of this crazy thing called the iPod. It was also the peak age of lifestyle diseases including high cholesterol and heart disease.
What these diseases had in common was that they could be treated by a little white pill that was prescribed by primary care doctors. Sales reps became particularly effective because they could reach doctors who were considered high-prescribers.
"The cardiovascular drugs, the statins, those were targeted at tens of millions of patients and you easily had audiences of 100,000 or more making those treatment decisions," said Jude Konzelmann, managing principal at ZS Associates Inc., in an interview. "As a result, just to be able to do the education that was necessary with healthcare professionals, the pharmaceutical industry had to have these fairly large sales forces."
But those blockbuster primary care drugs that brought in several billion dollars annually began reaching the end of their patent life, and the flood of generic drugs meant pharma had to change its business model. With the decline of treatments like statins, so went the pharma sales reps. From its height at 101,000 reps in 2005, the number of reps in the U.S. market dipped to 76,000 by 2010 and hit its lowest level of just 66,000 in 2012. Rep levels have rebounded slightly since, hitting 71,000 in 2016.
With the decline of primary care drugs, big pharma was forced to find a new business model, giving rise to the age of specialty care drugs. Cancer was no longer a single disease with a massive patient population, but rather thousands of rare diseases all under the umbrella of oncology.
"There has been much more of a move to specialty diseases where there are smaller patient pools and smaller prescriber populations," said Konzelmann. Fifteen years ago, reps were trying to deliver an educational message based on brand choice, now the role of the rep has become much more multi-faceted, he added.
During the pharma sales rep heyday, reps were largely there to convince physicians to prescribe Crestor (rosuvastatin) over Lipitor (atorvastatin), both highly effective statins with incredibly similar profiles.
But niche markets mean that brands are no longer the differentiating factor. Now, there is often just one drug available to treat a certain patient population, and sales reps are put in a very different position.
Konzelmann noted that now reps are often in the role of account manager, providing the service of liaison between physicians and companies, and responsible for things including demonstrating new modes of administration (since little white pills have given way to biologics) and explaining reimbursement (because the payer system has gotten increasingly complicated).
Smaller markets also mean that patients are often at a different place in their journey when the sales rep comes into the picture. Previously, patients were easily diagnosed for commonly understood diseases. Now, physicians often need help identifying which patients should be screened for rare diseases or might be eligible for a certain drug.
It hasn’t only been the shift from primary care to specialty care that has caused the pharma sales force to diminish in size in recent years — it’s also access to physicians.
In an effort to curb sales reps’ influence over doctor prescribing habits, many hospitals and physician networks are limiting sales rep access to physicians. A report from earlier this year in JAMA showed that decreasing detailing — or time reps spend with physicians — also decreased prescribing of the drugs the reps were pushing, while increasing the prescribing of the non-detailed drugs. While the numbers from the study were relatively small, they were statistically significant.
Even though the JAMA report has been influential, the time reps get with doctors has been decreasing for the last several years. The number of physicians that are considered accessible is down to 44%, from as high as 80% in 2008, according to the ZS Associates 2016 AccessMonitor report.
But this isn’t consistent across therapeutic areas — urologists, rheumatologists, allergy specialists and dermatologists tend to be more receptive to seeing sales reps than oncologists and nephrologists.
Yet, even those doctors that give access to reps are spending less time with them — most reps now only have about three minutes with doctors, down from six minutes in 2012.
Even though doctors are spending less time with sales reps, that does not mean they aren't interested in the information the reps are peddling. In fact, many doctors are just choosing to get the information differently, or in ways that are more accommodating for their very busy schedule.
Doctors are spending an average of 84 hours a year on reading digital marketing material. And many drug websites now include a separate page just to educate physicians. Accenture research finds that one in four sales force interactions have been replaced by digital.
But sales reps still have their place, according to Konzelmann, who said digital has become a complimentary tool for many reps. Reps are now using iPads to answer questions about drugs or show research to doctors. They're are also using video chats after typical business hours to engage with physicians during convenient times.
Once a common practice, the giving out of free sample drugs has gone down greatly in recent years. This is due in part to the shift to biologics — many of which need to be refrigerated or stored in a certain way and can’t just be stuck in a back closet.
But the practice has also become frowned upon for a number of other reasons beyond the practical. About 10 years ago, the practice of sampling began to be criticized because it could interfere with prescribing habits. The drugs that reps most often brought in were the newer, more expensive drugs. This put the doctors in the awkward position of handing out a costlier treatment, even if it was not the most economical or the best fit for the patient, just because it was conveniently located.
So, much like restrictions on how much time reps can spend with doctors, many practices now limit or completely restrict sampling.
Further complicating the practice are guidelines from the Food and Drug Administration that make sure pharma manufacturers keep tight controls on how many samples they give out, as well as exactly who gets them. Companies are required to report to the agency who requested the samples, how many samples were requested, the number that was actually dispensed and identifying information on the receiver of the samples.
But that does not mean pharma reps are showing up empty-handed. Reps now can offer rebate or discount cards. While not as exciting as getting free samples, these can be just as helpful to patients in a world of rising costs.