Rep as a resource?


Anonymous

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Dr Dave, Thanks again for all you do. I am writing to ask if you or if you think any doc sees a rep as a resource or a potential resource? I have often heard managers telling us that we are a resource or that we should tell the docs that we are a resource because of our product knowledge or because we can help with prior authorizations etc. However, that's still self serving for the rep even if it is helpful. I agree that a solid rep should have that knowledge, but how could a rep truly show that they are a potential resource? I have always believed that if I do what I can to come from the doc's and patient's perspective and be spot on on my product, disease state, and managed care knowledge that it would lead to more credibility and time with the physician and would generate more rxs for my product based on it's merits. However, I am tanking compared to pushy reps who know nothing and don't give a crap about the docs or their patients. I recently read up on new reimbursement codes and opportunities for docs to bill for things they haven't been able to in the past and have tried to tie them into the disease state and products I rep. Some offices have that "aha" moment and get that I am different etc, but ultimately I have to gain rxs or I will be canned. Any thoughts?
 


  • DrDave   Jan 29, 2012 at 08:33: AM
Obviously, different doctors will have differing opinions, but I think reps are consistently good resources regarding:

-Raising awareness of new products/indications;
-Managed care coverage;
-Commercial insurance discounts.

I think there are ways in which reps could be better resources, but company policies and/or regulation often make it difficult. I think physicians would utilize reps more if they could:

-provide hands-on help with pre-auths and patient assistance;
-be less scripted when talking about the evidence behind their drugs. This one is tough, though, since you are so restricted from talking about any studies not referable to indication/PI.

Would you be willing to reveal what your product/class is? There may be something about your product beyond your control that affects prescriptions.
 


Dr. Dave, Thank you. Sure, I work for Forest and have for a long time. I have promoted 9 different products here. I also asked you about the antidepressants. I promote Viibryd, Savella, and Bystolic. There have been dozens of times when a doc has thanked me for being able to provide that "banter" and really get into the differences among products, for knowing the specific pharmacology, managed care, being authentic and realistic, funny and not annoying, etc. I like this job even though I am not only not appreciated but will probably be terminated this year for not fitting into the culture, speaking my mind, and classified as a bad influence to my partners. I work hard, have integrity, and am proud of what I do. It was hard to accept I wasn't valued at first, but I can't control what management decides.
It is frustrating to not generate more rxs though. I understand cost, generics, pressures, habit, but I know I am making a good case for choosing these meds for the right patients. What I don't know is what I am missing or not saying or doing that will convince the doc to prescribe more often. Its not like I've never kicked butt numbers wise, I have won everything you can over the years, but it's now been a year near the bottom.
 


  • DrDave   Feb 01, 2012 at 04:50: PM
I hope you don't take offense at my comments, but I think two of the three are tough sells. In the disease state of depression, as you alluded, there are now many generic options plus branded options that have as good if not better third party payer coverage than Viibryd. Bystolic is unique as a beta blocker, but, once again, in the disease state of hypertention, there are many generics (several of which have solid outcomes data).

Also, I sometimes think the number of "right patients" may be inflated in the minds of some reps. Things seem to happen in clusters, of course, but after quickly reviewing my schedule for the last week (80-100 pts), I didn't initiate/change a single antidepressant (although I did renew existing ones). I don't know how many pts I would have to see to find the "right" Viibryd pt, but based on my prescibing habits and volume, I'm guessing well over 1000.

Savella is a more complicated prescribing situation. I think its data is as good or better than any fibromyalgia drug out there, but the population is tough. The pts tend not to tolerate things well, so a lot of them quit after a month or two. A lot of the competing drugs have multiple indications, too, and sometimes better 3rd party payer coverage.

I don't know if any of that is helpful or not, but, no matter what, I hope things improve for you!
 


Thank you Dr. Dave, I would never be offended by your comments, I want to know what you are thinking, good or bad. Your comments are very helpful. I understand I am a rep, not a doc and am not qualified to make prescribing decisions and respect every prescriber's (doctor, PA, NP ) decision on which medication is the best for their patients. However, I do wish I had a crack at being your rep and making the case for the products I rep. I believe in these meds, not because they are necessarily "better" for every patient but I do think there are more reasons to choose them then those you mention.
Viibryd, adherence to therapy continues to be a significant problem for patients with depression. Maintenance therapy reduces the risk of relapse by at least 70%, but unfortunately, less than 50% of patients started on antidepressants ever reach that point and most discontinue on their own, without regard to your instructions or expertise. Yes, there are many reasons why a patient decides to be non compliant. The med works, so they stop. The med doesn't work, so they stop. You can't easily control that other than writing down instructions (verbal instructions are forgotten more then 50% of the time). What about side effects? The third generation antidepressants have published evidence to support higher compliance rates due to samples, safety, and AEs. Yes there are strong generic options, but where do you go after the one you chose doesn't work out? An SNRI? norepinephrine is associated with lack of safety in overdose, HR and BP increases, hot flashes, urinary hesitation, constipation. What about sexual dysfunction? Is that a deal breaker for some patients? Evidence supports it is. Weight gain? That too. So before you grab that Cymbalta or Pristiq, why not Viibryd? 1000 patients? Cmon, is that really fair? Okay, maybe it could be fair, but is it fair without giving Viibryd a chance to prove you wrong? Are you so sure that you aren't willing to put a dozen or so patients on it and see what happens? Prozac, Lexapro, and all the others were new once too.
 


  • DrDave   Feb 07, 2012 at 08:24: PM
You make good points, and I feel I should flesh out my antidepressant algorithms/habits (I'll admit it's always a mixture) for you. For reference, in the other recent antidepressant thread, these were my comments:

I generally think of SSRIs as safe and tolerable across the board, although I have had some patients who seemed to do better re: tolerability with Lexapro than with the others. Lexapro also has some unique post-stroke prevention of depression data, but that is a small niche for me. I have tried 2 or 3 patients on Viibryd for tolerability issues, but, frankly, it's because Lexapro is no longer sampled and these patients were between the financial rock and hard place - can't afford a branded co-pay each month and don't qualify for indigent programs because they're insured. Forest, at least in my area, is very responsive with sample requests. One patient has done well and uses the samples to stretch his prescription out for 2-3 months.

The SNRIs in my experience are less tolerable, and I don't consider them quite as safe as SSRIs due to blood pressure elevation. I like Cymbalta if there is a chronic pain comorbidity and will sometimes use it first line in that setting. Otherwise, for me, it's a second or third line choice.

Though not an "antidepressant" in the traditional sense, Seroquel has more robust depression data than the other atypicals, IMO. It is not as tolerable or safe, but for very refractory depression or in the setting of depression with bipolar red flags, I will use it. I personally don't use much Abilify, but I do have one patient on it who is doing exceptionally well after failing Seroquel. I will add, though, that lithium is dirt cheap, and in similar situations, it is a reasonable choice, too.

These comments focused on my use of branded anti-depressants. To give you a better sense of my prescribing environment, you should probably know-

I work for a small rural hospital in an area where unemployment usually runs 14-18%. Even with commercially insured patients, cost is a key factor in prescribing. I would add, however, that some of the lower cost choices are still very efficacious ones (as you correctly noted). For example, generic bupropion is a great augmentation add-on for efficacy issues or substitution for sexual side effect/weight issues. Lithium costs $4/month at low doses and is a very good augmentation agent, too.

Also, depression is a condition that responds to placebo roughly 25% of the time and rarely if ever goes into "remission" (in current parlance) more than 40-45% of the time with a single agent based on the data I have seen represented on many a viz-aid over the years. Consequently, I'm much more likely to combine cheap therapies before I switch to an expensive single agent in many cases.

As for giving it a try to be "fair," 10 or 12 patients is a very small N. If one of those 10-12 patients had serotonin syndrome on Viibryd, you would correctly respond that this was purely bad luck because the large N data does not support that this is a common side effect. Trying out a drug to test its efficacy in a small population and comparing it with other drugs is as flawed a thought process as measuring its safety or tolerability based on one bad personal experience. You have to go by the well designed trials in both cases.

Thanks once again for posting, and I look forward to your thoughts!
 


Dr. Dave, Thanks for your responses. They are very helpful in helping me understand different perspectives. I hope you don't find my responses offensive. I know I am not necessarily "right" but merely expressing a different perpective.

I agree, ssris have a MUCH better safety and tolerability profile than SNRIs or atypicals. They are safe in overdose and have no vital sign changes. That's a big deal. Norepinephrine is also associated with hot flashes, urinary hesitation, constipation, abnormal dreams, agitation, in addition to the cardio risks you mentioned.

I also agree that a dozen patients is a small and not significant "n", but you have to start somewhere to see if what the data shows is clinically relevant.
Also, yes, there is a historically significant placebo response with antidepressants. However, literature supports that much of this is due to the setting/environment of a clinical trial and the attention the patient is getting and is not duplicable in a real practice setting.
Also, there is no doubt that cost is a factor. However, isn't it really more of an excuse? Almost 100% of patients who seek free meds thru Forests PAP program are approved with stated income, no documentation. Also, when a doc fills out an exception form for a zero to low copayment on any insurance plan it is also almost always approved. Yes, this is more work...but how much more work is it than switching, tittering, and augmenting therapy?
Yes, lithium and seroquel are effective, but it could take a year to find the right dose of lithium and controlling a patient on Seroquel is great, IF you exhausted the options that would offer a patient a better QOL where they still felt like themselves and had the minimum safety risks.
Depression is no joke, it affects EVERYTHING. Docs and thought leaders always say "yea, the goal is remission" and that the traditional stepwise approach is the way to go, but I don't see it consistently put into practice.
 



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