by Dr.Harald Wiesendanger– Klartext
What the mainstream media is hiding
What ultimately counts for drug manufacturers in the doctor is his “prescription value”: How diligently does he write out prescriptions? But how do pharmaceutical reps even know that before they put him on the spot for the first time? How do your clients find out which doctors are worth the hassle of hitting up? Gigantic databases provide insight and can be tapped against horrendous fees. Dubious databases, accessible for horrendous fees, provide insight.
How does Big Pharma know which doctor their emissaries need to contact and what? How to catch him, keep him going and motivate him? How do you know it’s “Prescribing Value,” or PV for short? (1)
And this requires no bugs, no eavesdropping, and no smuggled spies. Companies like IQVIA, a monstrous, global business services provider based in Durham, North Carolina, provide perspective. With 79,000 employees spread over more than 100 countries, he achieves annual sales of almost 14 billion US dollars. (2)
This Goliath stands on two legs. First, Iqvia has become the world’s largest contract research organization (CRO); as such, it conducts clinical contract research for the pharmaceutical, biotech, and medical device industries. Second, it acts as an almost omniscient gatherer of any information that might be relevant to medical marketing. Its data pools, encompassing 56+ petabytes, are considered pure gold within the industry, and almost every pharmaceutical company accesses them. (3)
A gold mine called IQVIA
“Iqvia” has only been called that since the company’s predecessor, Quintiles, completed a $17.6 billion merger with a kindred spirit in October 2016: the controversial market research firm IMS Health, at the time the world’s leading provider of information about medical prescription behavior and drug sales figures. (4) With 45 billion data per year on “transactions in the healthcare sector,” which 14,000 employees compiled or bought elsewhere, then evaluated and processed – more than 300 of them at the German headquarters in Frankfurt am Main – IMS used 2.6 billion dollars per year around. (5) According to IMS, it captured “85 percent of the world’s prescriptions” and offered “approximately 400 million comprehensive long-term patient reports”. (6) Her clients included the top 100 pharmaceutical and biotech industries. As of April 2014, IMS shares were traded on the New York Stock Exchange.
The prices asked give an idea of how extremely valuable these treasures are for Big Pharma. 40,000 to 60,000 euros per year were due to obtain electronic access to one of around 40 databases offered – the “IMS DPM,” which meticulously listed the sales figures and turnover of each individual drug.
What IMS Health could do, Iqvia can do. Its “OneKey” database provides detailed behavioral and attitudinal profiles of 14.3 million healthcare professionals in over a hundred countries, including 2.1 million prescribers; it precisely records general practitioners’ and clinicians’ prescribing and referral behavior. Those who use Iqvia’s service know exactly how many prescriptions for which active ingredients of which brands a doctor issues, which patients with which indication, and which therapy decisions he makes or rather avoids. He knows “physician characteristics and practice patterns,” as Iqvia points out. He knows how quickly or hesitantly a doctor uses “new” treatment methods, switches from tried-and-tested remedies to “innovations,” and prefers original preparations or generics.
An Iqvia service called “Patient Journey” traces “the patient’s journey from diagnosis to therapy,” specifically “the roles of the physicians involved.”
Another service, Expert Profiling, helps companies assess how valuable a doctor might be for marketing; he analyzes its “scientific, indication-specific footprint,” measurable, “e.g., in publications, clinical studies, congress activities.”
So “you can align your marketing measures with pinpoint accuracy and decide who your messages will reach,” assures Iqvia on its homepage.
And, of course, there are also tools that can be used to “measure the performance of the sales force” – what good is the pharmaceutical representative?
Mercilessly spied on
“OneKey” ties in with a data pool still developed by IMS Health: ScripTrac, which is now being continued by the US company service provider Medacist. Here, too, IMS offered “information on accurate doctor descriptions” – including the names and addresses of over 31,000 resident doctors in Germany, i.e., every third. (7) “ScripTrac” was fed in part with entries from forms that doctors filled out once a year for a fee. Believe it or not, 600 questions explored not only the prescribing behavior but also the patient structure of the practice, its organization, and even areas of interest, attitudes, and character traits. The doctor who was spied on stated on a five-part scale – from 1: “do not agree” to 5: “completely agree” – to what extent he agreed with statements such as: “I like to have a lot of people around me,” “I’ll try something new things, even if there is a small risk involved,” “I enjoy working on new theories and new ideas,” “If I am successful, I want to show it to the outside world,” “The reputation that you as a doctor is important to me,” “I usually succeed in convincing others of my opinion.”
ScripTrac stands for “Prescription Tracking”: the tracking of medical prescriptions with a depth of focus that is almost detectable. Which doctor wrote which prescriptions, how often, and for what? Does he or she prescribe pharmaceuticals particularly often, on average, or rarely? Which originals, which generics? Over what period? How soon after an “innovation” was launched did he start prescribing it? For which indications? Was he prescribing a particular drug for approved uses only, or beyond, off-label? How far did he go? Did he prefer preparations from certain manufacturers? The pharmaceutical industry appreciates such informative insights so much that they are not put off by even the most brazen price tag.
The market is correspondingly hotly contested. A number of other service companies compete with Iqvia and Medicast, most with several hundred to thousand employees and sales in the three-digit million range at least. They have names like Dendrite – since 2007, after a takeover, Cegedim Dendrite -, SDI Health, and Wolters Kluwer. The oldest physician data broker, Medical Marketing Service (MMS), has operated out of Schaumburg, Illinois, since 1929. Some offer additional services such as email marketing; special software that helps to assess the performance of sales representatives as well as the yield of certain sales promotion measures; or statistics on what a doctor was looking for on the internet, such as how often he visited a particular pharmaceutical company’s website. Some are limited to the primary US market; others provide insights into many other national markets. Some focus on resident doctors, while others include clinics, homes, and pharmacies. But one thing connects them all: their core business, the provision of data, data, data.
Where does the data come from?
Where the data came from can only be guessed for the most part. Most of the sources are obscure, the vendors are guarding them like a hoard of gold, and it is.
However, at least one main source has been well known for a long time: the oldest and largest professional body of the US medical profession, the American Medical Association (AMA). Their physician database, the Physician Masterfile, is widely recognized as the most sophisticated in the world. It provides demographics for all 900,000 US physicians, living and deceased, AMA members and non-members, practicing and retired. And that’s how the AMA runs a lucrative business: in 2005 alone, it earned $44.5 million from it. (8) It issued the very first usage license back in 1929 – to MMS.
Data protection tends to be handled rather loosely in America. But even there, resistance to the rampant data trade has increased since the turn of the millennium. In 2006, New Hampshire banned the sale of prescription data for commercial purposes (9), and other states have since followed suit. As a result, the AMA felt compelled to decide on an official “Prescribing Data Restriction Program.” (10). Since then, US physicians can use an online form on an AMA website to object to the disclosure of their data to Reps and their companies.
But the data business continues to flourish. Because the AMA is because prescribing data remains available “for beneficial purposes” such as “evidence-based medical research, structuring clinical trials, effective drug recalls, assessing post-approval benefits and risks, and many more purposes.” (11) And some of these purposes continue to be found for clever data collectors. This explains why reps today are no less knowledgeable about physician prescribing behavior than they were decades ago.
In addition, the wealth of data from medical professional organizations is just one source among many. The art of analysis consists in linking it with what others provide. For example, IMS Health had logs of over 70 percent of all prescriptions filled in pharmacies. The names of patients are anonymized in it. Nevertheless, the prescribing physicians can be located, even if they do not appear by name – namely by their state license number, a code assigned by the US Drug Enforcement Administration (DEA) (“Drug Enforcement Administration Number”), or an “identifier.” every pharmacy gives. (12)
But how do reps know in advance, even before they enter a practice for the first time, that they also have precise information about the attitudes, habits, interests, and preferences of the doctor they visit?
Telltale surf tracks
The internet makes it possible. Doctors use it too at work and in their limited free time. Like all of us, they leave insightful traces that certain companies are keenly interested in. They also collect and store such data – and sell it to the highest bidder. That’s what they live on, despite all official assurances; their business model is based on it. Whether it’s queries typed into search engines or orders in online department stores, accessing certain websites, liking specific posts, following certain links, entering into chat rooms and forums, downloading documents, images, and films: all of this provides the material in abundance, from which oppressively detailed personality profiles can be created. They are, of course, available to the professionally prepared representative of the 21st century.
Some doctors constantly provide additional data online, often voluntarily, sometimes unknowingly. Practice software, which they get as a gift from pharmaceutical companies, forwards prescription data to analysis centers via an installed interface (13); From there, they get onto the client companies’ monitors and finally appear on the representatives’ laptops. They are, therefore, well prepared: They know in advance where to start.
It also happens that the doctor is recommended to use the services of a “medical billing expert.” The offer: the doctor copies all of his patient data onto a stick, which the pharmaceutical representative forwards to a company employee; The doctor then gives the doctor free tips on how billing costs can be reduced. There is no control over what ultimately happens to the data. Research by Spiegel in 2012 brought this blatant violation of medical confidentiality to light. (14)
On the horizon: the RoboDoc as an industry-controlled enforcement assistant
It takes little imagination to predict that data will soon also flow in the opposite direction – from Iqvia computers to practice and clinic computers. It will happen because medicine is about to enter the age of digitization. As it descends into the workforce, it disempowers the practicing physician. The empathic healer ends up as an industry-driven prison clerk that a RoboDoc’s AI could eventually render obsolete. On the one hand, the doctor should act as “evidence-based” as possible – on the other hand, this “evidence” consists of a constantly growing amount of information that overwhelms even the most brilliant human brain; 9,000 clinical studies are added every year worldwide. To evaluate big data and draw the correct conclusions from it, service providers such as Iqvia are available, commissioned by overpowering industries that smell big business.
Industrial engineer Frank Wartenberg, Iqvia’s Germany representative and chairman of a “Federal Commission for Digital Health” who wants to “develop a future-proof e-health strategy for Germany” and “create concrete benefits for big data,” helps to look into the future. (15) The doctor’s treatment plans “become more verifiable,” says Wartenberg happily. “Because the better the documentation about therapeutic approaches and treatments is, the better it can be understood whether the right decisions have been made.”
This makes doctors “understandably also afraid,” admits Wartenberg. “The other side is the variety of therapies. A doctor today has 300,000 therapy alternatives for a cancer patient. 50 years ago, people still said “diseases of the blood”; today, there are 200 different types of blood cancer. The variety is increasing enormously, as are the findings and the therapy alternatives. It is becoming increasingly more work for doctors to keep track of all this, and it is not easy to make the right decision. There will be systems that can help doctors. If the patient has certain characteristics, for example, when you look at the treatment history, you can estimate with a high degree of probability whether a certain therapy works better than another. (…) The doctors will have to rely on systems that are developed by others and partially fed with content.” (16)
Soon, a doctor will only need to enter the ICD-coded diagnosis of a patient and a few other personal data – fractions of a second later, algorithms will provide him with a therapy proposal that is perfectly compliant with the latest scientific guidelines. Since the “evidence” consists mainly of pharma-sponsored research, it is easy to guess what the proposal will look like.
Spared by the rep: the “forget-it practice.”
Even today, data pools such as “OneKey” and “Scriptrac” provide pharmaceutical companies and their envoys with an oppressively accurate picture of every single doctor recorded. The medical journalist Hans Weiss found entries like (17)
– “A forget-it practice, small, not very innovative, without pronounced practice strengths, with a medium to low score, preferably generics.”
– “All-rounder, large, innovative practice, no interest in naturopathy, weak with dementia and gastro.”
– “Eccentric, (…) promises a lot, (…) tries everything, type ‘butterfly’, often conducts application observations, reacts with an above-average increase in prescriptions.”
– “Cautious introvert, (…) avoids risks, builds on the familiar, little communicative, (…) tends to lag behind.”
Such insightful portraits should “optimize the communication between the doctor and the manufacturer as needed” in order to “get the maximum growth out.” A “new dimension of defining doctor profiles and exploiting the prescription potential” opens up. (18)
A top manager from Eli Lilly also divides the medical profession into five drawers, depending on their prescribing potential but also on their character qualities. He tailors his marketing plans to two of them: “high flyers” don’t stick to the rules and like to try out new medicines. “They tend to treat very aggressively, with very high doses, and also for uses that aren’t approved by the agency.” to a brand.” (19)
“Advanced training” between beach, brothel, and casino
Experience has shown that especially social occasions open the ears, hearts, and brains of demigods in white. Industry-sponsored trips “create shared memories,” explains the former managing director of a pharmaceutical company, explaining the well-established ulterior motive. “When you travel, you get to know people you might otherwise have no access to. Travel creates freedom, you move more easily outside of the usual framework, and you discover neglected sides of your personality. In short: Travel can have a disinhibiting effect. Especially when you travel without your better half.”
Officially, such excursions, which are completely free of charge for invited doctors, are, of course, called “further training,” and of course, there is also an official agenda. “But do you think we fly sun-weaned doctors halfway around the world to lock them up for two weeks in a seminar room where there is only neon light again (…), and tables with endless columns of numbers are thrown against the wall? (…) No, the gentlemen should have their fun, and they get it. The beach is not far, nor are the brothel and casino. We make sure it’s a wonderful experience. And it works – the invited doctors remember us fondly and always have an open ear when our representatives ring their bells. They sell our products to their patients.” (20)
A cultural highlight such as a music festival also attracts – “from then on, our representatives have an easy job.” They bring snapshots that have been taken, which we look at together. Everyone raved about the great evening again, “we exchanged little anecdotes, we got along really well – selling our products is no longer a problem at all. Without any exchange of factual information.” (21)
Karnevalesk: “Advisory Committee” made up of 19,000 doctors
Doctors in private practice, too – especially if they have attracted attention in the professional world through diligent publishing, talent as a speaker, a high number of prescriptions, and an outstanding reputation among colleagues – often enjoy the benefits with which the medical elite is treated and wrapped up: be it as “Authors” and “speakers”, be it as “advisers”. Anyone who thinks there could only be a few is grossly underestimating the industry’s need for freelancers: in 2009, Forest’s “advisory committee” had a whopping 19,000 members. (22) According to an Australian survey, one in four medical specialists was on the advisory board of at least one pharmaceutical company within a year. (23)
Prima usually receives an offer from the medical profession to organize a lecture for the general public or in front of specialist colleagues. That flatters the doctor; after all, he is trusted to publicly demonstrate his medical competence, a wealth of experience, and rhetorical skills. And it is helpful to him because it increases his awareness and draws new customers’ attention. On top of that, he is spared any hardship: the pharmaceutical representative takes care of the implementation.
For Big Pharma, an informative show is taking place: How confident is the doctor? How well do his listeners receive him? How confidently does he deal with critical questions? If he proves himself as a speaker in a smaller circle at a local event, he has qualified for higher tasks. He deserves invitations to appear at congresses or as part of medical training as an official “speaker,” if not even as a “keynote speaker.” For a handsome fee, of course.
(Harald Wiesendanger)
Remarks
More in Harald Wiesendanger: The health care system – how we see through it, survive and transform it, chap. 6: “Trained demigods” and chap. 7 “Insatiable Renters.”
1 Industry magazine Pharmaceutical Enquirer defines this metric as “a function of prescribing opportunity and attitude towards it, plus external influences. Physician profiles incorporating these multiple dimensions make it possible to analyze the ‘why’ behind the ‘what’ and ‘how’ of physician behavior.” C. Nickum/T. Kelly: “Missing the mark(et)”, Pharmaceutical Executive, 2005-09-01, www.pharmexec.com/pharmexec/article/articleDetail.jsp?id=177968, accessed 2019-05-30.
2 https://en.wikipedia.org/wiki/IQVIA, retrieved on 2/10/2023.
3 See www.iqvia.com, www.thehealthcareprof.com, www.imshealth.com.
4 For criticism of IMS Health’s data collection, see DiePresse.com, August 26, 2013: “Patient data: corruption prosecutor investigates”; DiePresse.com, August 22, 2013: “What doctors sell for 432 euros”; Kurier.at, August 22nd, 2013: “Medical Association wants to ban data trading.”
5 According to Wikipedia.com and Wikipedia.de, entries “IMS Health” retrieved on December 29, 2016.
6 Cited by Adam Tanner: “Company that Knows What Drugs Everyone Takes Going Public,” Forbes 6 January 2014, www.forbes.com/sites/adamtanner/2014/01/06/company-that-knows-what-drugs-everyone -takes-going-public, accessed 2016-12-29.
7 See Hans Weiss: Corrupt medicine – doctors as accomplices of corporations (2008), p. 27 ff.
8 Steinbrook, R. For sale: Physicians’ prescribing data, New England Journal of Medicine 354/2006, pp. 2745-2747.
9 PC Remus, First-in-the-nation law pits NH against drug industry, New Hampshire Business Review, 11/10/2006.
10 https://assets.ama-assn.org/resources/doc/dbl-public/x-pub/pdrp_brochure.pdf, accessed 29.5.2019.
11 https://apps.ama-assn.org/PDRP/, retrieved on 29.05.2019.
12 According to R. Steinbrook, op. cit.
13 Der Standard, August 29, 2013: “Software company installed interface to market researchers for doctors,” retrieved on May 17, 2019.
14 Tagesanzeiger.ch, March 26, 2012: “Big violation of medical confidentiality.”
15 www.wirtschaftsrat.de/wirtschaftsrat.nsf/id/bundesfachkommission-digital-health-de, retrieved on May 17, 2019.
16 In an interview with Health Relations, October 11, 2018: “Digital Trends in Healthcare: Dr. Frank Wartenberg from IQVIA,” www.healthrelations.de/dr-frank-waitenberg-iqvia/, retrieved on May 17, 2019.
17 Quoted from Weiss: Korrupte Medizin, loc.cit., p. 30.
18 quoted from Weiss: Korrupte Medizin, loc.cit., pp. 28-30.
19 Quoted from Hans Weiss: Korrupte Medizin, loc.cit., p. 130 ff.
20 John Virapen: side effect death. Bogus science, corruption, bribery, manipulation and fraud in the pharmaceutical world (2012), p. 90 f.
21 Virapen: side effect death, loc.cit., p. 92 f.
22 J Edwards, “Suit vs. Forest Labs names execs linked to alleged lies about Lexapro, Celexa,” CBS News, Moneywatch 02/26/2009.
23 D.Henry/E. Doran/I Kerridge et al.: “Ties that bind: multiple relationships between clinical researchers and the pharmaceutical industry,” Archives of Internal Medicine 165/2005, pp. 2493-2496.
This text is part of a series of articles with the following additional contributions:
1) Trained demigods – How doctors become drug dealers
2) Visit from the Rep – Mendacious Friendship based on the script
4) Off-label – crossing borders as routine
5) Application observations – the doctor as “researcher.”
6) Well kicked – When doctors let themselves be greased
7) “As you do to me, so do you” – reciprocity as the secret of success
8) Softened – education and training as brainwashing
9) Insatiable Renters – The uncanny power of paid opinion leaders
10) Among Gorillas – Silverbacks call the shots
11) As KOL to the Golden Nose – Why “Key Opinion Leaders” have taken care of it
Pharmareferent, Big Pharma, Pharma Marketing, Pharma Industry, Prescription Value, Harald Wiesendanger