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Drug makers wine and dine doctors for business

By REGISTER STAFF WRITER

June 20, 2005

About four times per week, Dr. L.J. Twyner of Newton

goes out to dinner without ever having to reach for

the check.

His dinner companions are pharmaceutical sales

representatives often called " detailers " who are paid

to track the prescribing habits of Iowa physicians.

They pay regular visits to the doctors' offices,

handing out product samples, gifts and free meals, all

in an effort to persuade the doctors to prescribe more

of their products.

Twyner said the detailers influence his

prescription-writing habits although not, he

emphasizes, to the detriment of any patients.

" That's why they are employed, " Twyner said of the

detailers. " If they are the per- son you see all the

time and that's their drug and there are five other

drugs that are equal the physician is more likely to

write (a prescription for) that product. "

In March, two eastern Iowa detailers were fired after

accompanying Twyner to a Cedar Rapids club featuring

nude dancers. Their employer later argued that the

trip could have " almost catastrophic repercussions "

for the company, which makes $10 billion in sales each

year.

Consumer advocates and medical ethicists say the case

highlights a persistent problem in the medical

industry: Doctors, they say, are too quick to accept

free meals, token gifts and lucrative consulting

contracts offered by profit-minded companies with

products to pitch. They say patients ultimately pay

for the billions that are spent each year on

pharmaceutical marketing aimed directly at doctors.

" There's no such thing as a free lunch in this

industry, " said Dr. Marcia Angell, former editor of

the New England Journal of Medicine and a senior

lecturer at Harvard Medical School. " These costs are

added directly to the price of the drugs, and the

consumers pay for it. "

Industry officials say their marketing efforts are

beneficial to doctors and patients. With thousands of

medications now on the market, they say, doctors need

to know about new products that can help patients live

longer and better lives.

While experts like Angell argue the companies' efforts

are tainted by profit, the industry officials say such

conflicts exist in all businesses.

" There are a lot of moral issues out there in a lot of

industries, " said Brad Sullivan, the education manager

for the National Association of Pharmaceutical Sales

Representatives.

Jeff Trewhitt of the Pharmaceutical Research and

Manufacturers of America says the gifts and meals are

" basically a token of gratitude " for the doctors

taking time out of their busy schedule to meet with a

sales rep.

State Rep. Rob Hogg, a Cedar Rapids Democrat,

sponsored legislation this year that would have

restricted drug makers' gifts to Iowa physicians.

However, the bill never gathered momentum and failed

to reach the floor of the House or Senate for a vote.

" The cost of prescription drugs is literally killing

people, " Hogg says. " These stories you hear of people

having to choose between food and medicine are true.

I've met people who are spending $1,000 per month on

prescription drugs. "

The process of marketing drugs to doctors begins with

global data-mining companies, such as IMS Health of

Connecticut, collecting information on prescriptions

that are being written throughout the world. IMS

Health officials say their databases now contain

detailed information on 90 percent of the

prescriptions written in the United States. They say

the data do not include patient names, although the

doctors are identified.

IMS officials won't say where they get their

information. " I don't think that's something we want

to talk about, " says company spokeswoman Caroline

Lappetito.

IMS sells the data to drug makers that use it to

identify physicians who are prescribing drugs produced

by competitors. The drug companies pass that

information along to their physician detailers. Often,

those detailers will show up at the doctors' offices

with free product samples, pens, note pads, laser

pointers, stuffed animals and an expense account to

pay for meals.

Detailer's visits

Until recently, Carr of n worked as a

detailer for Schering-Plough, one of the world's

largest drug companies. Part of her job entailed

regular visits to the medical office of Dr. L.J.

Twyner of Newton.

" He's a big prescriber, " Carr testified at a recent

state hearing dealing with her request for

unemployment benefits. " He was a high target for me —

both for Levitra and Avelox. He was ‘Top Ten.’ He was

a target that I had to actually, physically, track for

the company. He had the potential to be a big

prescriber and to increase my market share. "

According to Carr, she wasn't the only detailer trying

to influence Twyner's prescription-writing habits.

" He is entertained four nights per week by

pharmaceutical representatives, " Carr testified. " And

he is known far and wide for prescribing not on a

clinical . . . " Carr stopped in midsentence, then

added: " It's on who he likes. He rewards people. He

rewards people personally. "

Twyner acknowledges that he does go out to dinner

about four nights per week with detailers picking up

the tab.

" It's all on the drug companies, " he says. " And that's

all legal. They are allowed, I think, $125 per meal,

per person. "

As for his motives in prescribing certain drugs,

Twyner said he doesn't set out to " reward " detailers,

but his contacts with them do have some effect. When

choosing between competing, identical drugs that are

of equal benefit to patients, he said, he'll often

prescribe the drug supplied by a company with which he

has had the most recent contact.

Trip to Woody's

On the night of Feb. 23, Carr and three other

Schering-Plough detailers took Twyner to dinner in

Cedar Rapids. Afterward, Carr later recalled, Twyner

said he wanted to go " bar hopping. "

One of the Schering-Plough reps paid for everyone's

dinner with a credit card and added $50 to the tab,

which she then took back in cash. State records

indicate she gave the $50 to one of her male

colleagues who later accompanied Twyner and Carr to

two taverns and, at Twyner's suggestion, to Woody's, a

bring-your-own-bottle " gentleman's club " that features

nude dancers.

Twyner says he typically limits his outings with

detailers to " dinner and drinks, " and the trip to

Woody's was unusual. " I usually don't do that, " he

says. " It was that one particular time I wound up

there. It probably was a mistake. "

In March, when Schering-Plough executives learned of

the trip to Woody's, they fired Carr and two of her

colleagues.

At Carr's unemployment hearing, company sales manager

Ron Maxwell testified that the trip to Woody's

violated the company's policy that prohibits detailers

from providing doctors with entertainment. " If you're

taking someone to dinner and you're discussing

products, that is acceptable, " he testified. " But a

gentleman's club is not a venue of business activity. "

Maxwell said the trip to Woody's could have " almost

catastrophic consequences " for Schering-Plough, but he

didn't elaborate. A Schering-Plough spokeswoman

declined to answer any questions about the Carr case

or the company's marketing efforts.

The company has had its share of legal troubles

related to marketing. In 2001, the Federal Trade

Commission accused the company of paying two other

drug makers millions of dollars to delay the launch of

a cheaper, generic version of a Schering-Plough

medication. In 2003, the company's sales techniques

were the focus of a grand jury investigation. In 2004,

the company paid $314 million to settle charges of

violating anti-kickback laws. That same year, the

company paid $500,000 to settle allegations of bribery

by one of its foreign subsidiaries.

Personal time

In defending her actions, Carr testified that she went

to Woody's reluctantly and only because she was afraid

Twyner might otherwise write fewer prescriptions for

Schering-Plough products. But when asked about the

company policy that prohibits entertainment for

physicians, Carr said she was at Woody's on her

personal time.

" People buy things from people they like, " she

explained. " And it would be just as if one of our

local physicians in town passed away and it was my own

personal time, but I went to his funeral. And there

were a lot of prescribers there. You know, I did it on

my own personal time, but I did it so that I could

also see other physicians and grow relationships with

those physicians. "

Drug companies are spending more money than ever on

marketing, but there are signs of increased resistance

from physicians.

Earlier this year, a small group of Cedar Rapids

physicians publicly stated that they're refusing meals

and gifts of any kind from detailers, likening the

practice to legalized bribery. And Dr. Steve s,

a family physician and president of the Iowa Medical

Society, says an increasing number of Iowa physicians

are taking a similar stance.

" Most physicians around this state think this is all a

bunch of nonsense with all these gifts and these goofy

things that drug companies do, " he said. " It got to

the point where you'd have seven or eight drug reps

coming into your office every day. So, many medical

practices — and mine is an example of this finally put

a stop to it. We said, ‘If you come today, there will

be only one physician you can see, and you only have

five minutes of his time.’

Doctors are really restricting drug reps' access to

physicians in the office setting and I think that's

becoming the norm.

Guidelines create industry for 'ethically compliant'

gifts

Several years ago, it wasn't unusual for drug makers

to give physicians golf balls, concert tickets and

free trips to resorts.

But three years ago, the American Medical Association

and the Pharmaceutical Research and Manufacturers of

America adopted voluntary guidelines that restrict

gift-giving to modestly priced meals and to " medically

relevant " products that cost less than $100.

Enforcement of the physicians' guidelines is left to

state medical boards. Although it has never happened

in Iowa, a doctor who is thought to have violated the

standards on gift-giving could be sanctioned for

unprofessional conduct.

The gift-giving guidelines have created a small

industry built on " ethically compliant " physician

freebies. One gift supplier, Elsevier, advertises its

services this way:

" Sales reps: Get your foot in the door with medically

relevant premiums from Elsevier! Capture physicians'

attention while providing useful medical information.

Provide honoraria for dinner meetings or symposia.

Ensure multiple face-to-face visits with a product

series. "

A competitor, PharmaDesign, advertises " the very best

in physician give-aways, " and the company's Web site

says it has trademarked the phrase, " The doctor will

see you now. "

One gift supplier, Medsite, dispenses " reward

certificates " to physicians at the behest of

pharmaceutical companies. The doctors can use the

certificates to claim stethoscopes, office lamps and

other items offered through an online catalogue.

A 1999 study published in the American Journal of

Medicine showed most doctors didn't believe gifts from

pharmaceutical companies influenced their own

prescribing habits. However, the same study showed 80

percent of doctors believed the gifts did affect their

colleagues' prescribing habits.

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