I have posted previous notes about how drug companies were exploring e-detailing, using the web to market drugs to physicians, because physician office calls have gotten too expensive and less productive (see: How E-Detailing May Lead to Greater Knowledge by Physicians about Drugs). Much of the current success of Big Pharma companies relates to their expertise as sophisticated marketers. An important element of this is knowing is identifying who one’s customers are and how to sell to them. Increasingly, they are realizing that a large and growing percentage of physicians are now hospital employees. In hospital settings, the drugs available for treatment are listed in the hospital formularies. These lists are determined by efficacy, cost, and by the pharmacy benefit managers (PBMs) working in concert with the health insurance and drug companies. A recent article discussed how drug firms have been redirecting their sales calls from physicians to hospital managers (see: As Doctors Lose Clout, Drug Firms Redirect the Sales Call). Below is an excerpt from it:
…[W]hen the GlaxoSmithKline PLC saleswoman began plugging two new lung-disease drugs to a big San Diego hospital system this spring, it was to an administrator who doesn’t see patients but helps write the menu, also called a “formulary,” of approved medications. [She] urged the administrator in the system, Sharp HealthCare, to consider the two drugs’ effectiveness. It was the kind of pitch she once used to persuade doctors to write prescriptions…..There are about 2,600 doctors in the Sharp system. [Her] sales calls are part of a shift that is rewriting the drug-marketing playbook. As hospital systems get bigger, they are putting distance between their doctors and drug sellers, making it harder for pharmaceutical companies to get quick acceptance of newly approved medicines and putting pressure on profits.Today, 42% of doctors practice as salaried employees of hospital systems, up from 24% in 2004….As a result, the pharmaceutical industry is shifting its sales efforts from doctors to the institutions they work for. In 2005, drug companies employed about 102,000 U.S. sales representatives, who mostly pitch to doctors. By mid-2014…, their numbers were down to about 63,000. Stepping in are so-called key-account managers …who build relationships with administrators. The 20 biggest drug companies employ roughly 600 key-account managers, three times the number five years ago, according to ZS….Sales reps still account for the bulk of drug sales. But companies are increasingly deploying key-account managers in regions where hospitals have moved more quickly to buy practices. Eli Lilly & Co…. last year scrapped its old sales-rep approach in six metropolitan areas including Boston and Salt Lake City in favor of key-account teams.
This is just one more step in the movement toward “Big Medicine,” alternatively referred to as the institutionalization of medicine (see: The Institutionalization of Healthcare; Consequences of Big Medicine?; Physician Private Practice Declines; the Last Barrier to Emergence of “Big Medicine”; The Transition to “Big Med”: Need for Emphasis on Standardization and Cost; Health Systems Use Their Regional Dominance to Muscle Insurance Companies). The evolution of Big Medicine involves the transfer of power and strategic decision-making to large hospital systems, health insurance companies, Big Pharma, and the federal government as the major source of funding for healthcare.
What is the next macro trend that will have a major effect on clinical workflow and physician decision-making and responsibilities? I believe that, increasingly, patient management for routine office visits will be algorithm driven, which is to say determined by automated clinical protocols. Most such routine visits will continue to be the responsibility of primary care physicians but such work will increasingly be assigned to nurse practitioners or even pharmacists for tasks such as vaccinations (see: A Solution to the PCP Shortage: Nurse Practitioners). I think that for most patients, this will not result in a decline in the quality of care and perhaps even some improvement. If the triage nurse identifies a more complex problem during the visit, the patient will be turfed to a physician. This will constitute the ultimate “solution” to the shortage of primary care physicians.