The news that doctors in Shanghai and Hunan hospitals received kickbacks on drugs has once again pushed a hidden profession, the medical representative, to the forefront. This profession, which has long been hidden behind the public, does what’s specific work at ordinary times? Is there a what relationship between doctors’ drug rebates and them? Is this profession a kind of original sin at all, or should it have their professional attributes and professional honors?
This article will open up history for you and reveal the growth and change history of medical representatives in China.
China’s pharmaceutical representative system was introduced into China by foreign pharmaceutical companies. The general consensus was that the earliest importer was Xi’an Janssen. This joint venture pharmaceutical company was established in 85. The foreign shareholder is Johnson & Johnson, the world’s famous pharmaceutical giant. Before entering China, Johnson & Johnson has a history of more than 100 years in the United States. Most of the drugs developed by these large international pharmaceutical companies are developed by themselves and have strict patent protection. These original drugs undergo long pharmacological research and clinical trials before entering clinical practice.
When these drugs enter clinical practice, pharmaceutical companies have two market demands:
First, from the perspective of evidence-based medicine, introduce the efficacy and usage of drugs to doctors and timely feedback adverse reactions;
Second, due to competitive considerations, doctors are expected to use more drugs produced by their own companies.
Medical representatives are based on these two needs.
In response to the above two demands, the promotion of pharmaceutical companies abroad is divided into two parts: one part is called medical education and the other part is called brand promotion.
The functions of these two parts are undertaken by different internal units, The former is carried out by the medical team. The basic rule is that the brand name of the product must never be mentioned. Can only do the basic concept education of the market, That is, the promotion of pure medical concepts, All materials used in the process are also based on pure scientific publications such as medical documents, guidelines and consensus, as well as direct statements by doctors, and cannot be added with any brand content. In providing services to doctors, academic basis is as far as possible, but there is no denying that there will be its own perspective on the interpretation of data.
They will often support the academic activities of societies, associations, etc., Sometimes some neutral academic platforms are established to help doctors master new knowledge and ideas. The standard of such activities is not to interfere with doctors’ free discussion. It is entirely based on the opinions of doctors. Some companies even stipulate that marketing department and sales department personnel are not allowed to participate in high-level academic discussions, so as not to affect the neutrality of these academic activities.
Brand promotion is the responsibility of the marketing team of the pharmaceutical company. That is, according to the indications of the product and the supporting medical literature, The development of product market positioning, segmentation, and the development of brand related promotion activities. At this time, the brand promotion activities are in the direction of expanding the use of products, with various forms of activities, including meetings, competitions, case discussions, etc.
After Johnson & Johnson entered China, it cloned this set of practices to Xi’an Janssen. As a result, China’s first batch of medical representatives began to take to the historical stage.
The conditions for recruiting medical representatives in Yeung Sum were very harsh. Either doctors with clinical experience or practitioners in pharmacy must be able to read medical documents without barriers and communicate professionally with frontline doctors, many of whom have already obtained the qualification of attending doctors.
After these candidates entered Janssen, At least 30 days of training, including professional knowledge, interpretation of the latest research papers, communication skills with doctors, academic slide speech drills, etc. Of course, the salary is also very attractive. In the late 1980s and early 1990s, the average doctor’s monthly salary was only a few hundred dollars, and the salary of Janssen’s medical representative started with several thousand dollars.
Janssen was later called Huangpu Military Academy, the representative industry of Chinese medicine, the president and sales director of a large number of international pharmaceutical companies in Greater China. Many people started their first jobs in Janssen.
In the eighties and nineties, The whole medical industry in China is in a state of complete disuse. After the founding of New China, There is a serious shortage of doctors, Many barefoot doctors slowly entered the ranks of doctors in public hospitals, In addition, during the ten-year Cultural Revolution, many medical graduates escorted by workers, peasants and soldiers did not have enough clinical medical knowledge at all. In addition, in China at that time, doctors basically had no chance to learn again after working, resulting in a large number of unqualified doctors treating patients in the frontline.
On the other hand, the long-term closure has left China’s medical system free from the international mainstream academic system for a long time. The overall medical level is extremely low and it knows nothing about the development of international mainstream medicine.
Many people miss that era in those days, but they actually don’t understand it. At that time, the largest 3A hospital in the country had only about 500 varieties of drugs. The treatment method was very single and the mortality rate of patients was also very high.
Against this background, Foreign medical representatives enter the Chinese market, First of all, it serves as a bridge for the training and knowledge renewal of China’s medical system. They go to hospitals mainly to transmit the core information of products. Change the doctor’s prescription habits, Collect information feedback from doctors on the varieties they are responsible for, Case collection. In addition, He will also communicate with doctors about the latest progress and research in this disease field and support the organization of academic conferences in various professional fields. Therefore, when medical representatives came to the hospital, they would be welcomed by the hospital. Some medical representatives went to a certain city, and the presidents of several hospitals would jointly invite medical representatives to dinner and invite them to visit their own hospitals.
Around 1990, a large number of foreign pharmaceutical companies landed in China and set up joint ventures. Janssen’s medical representative system was quickly followed by other foreign companies. At the same time, domestic doctors also fully benefited from the renewal of knowledge and technology brought by the medical representative system.
Most endocrinologists know the story of Baitangping.
Baitangping, China’s largest imported hypoglycemic drug, Produced by Bayer Company of Germany, Its effect is mainly to control postprandial blood sugar. But in the 1990s, when Baitangping just entered China, Many endocrinologists in China simply do not know the importance of postprandial blood sugar in controlling diabetes. Bayer’s medical representative, Of course, it also includes the entire company’s academic promotion system. It took almost five or six years to make doctors realize the importance of postprandial blood sugar through literature, education and funding for diabetes research in China, thus laying the academic foundation for the use of products.
They organized doctors to conduct postprandial blood sugar tests, Helping hospitals take postprandial blood glucose tests, organizing China’s top diabetes experts to attend the annual diabetes conference in the United States, and allowing them to have face-to-face communication with doctors in the United States. After learning the latest diabetes theory, they returned home to slowly guide other colleagues, thus quickly improving the treatment level of diabetes in the country.
After communicating with their counterparts in the United States, these authorities in the Chinese medical field found that the clinical data of diabetic patients in China after taking Batangping can be directly published in American medical journals, which also objectively helps the Chinese medical field to integrate with the international academic field.
There are countless stories like this, Laparoscopy in General Surgery Enters China, It was first promoted by a French enterprise. They first gave lectures to doctors in Chinese hospitals. This paper introduces the technique of laparoscopy, After that, excellent Chinese surgeons will be sent to their own training centers in France for training. After the trainers of these pharmaceutical companies have completed their theoretical training, It will instruct Chinese doctors to do experiments on simulated humans and then perform operations on animals. After completing this series of trainings, the Chinese doctors will be introduced to watch and study in French hospitals until they can do some simple participation. After returning home, the doctors will introduce laparoscopy, an advanced surgical technology, to China.
It can be said that, Subjects that have made great progress in the Chinese medical field in the past decade or two, Such as orthopaedics, Cardiovascular surgery, General surgery, Basically, under the medical representative system of foreign enterprises, Growing up with the academic support of foreign companies. Until today, Outside and outside the operating rooms of major hospitals in China, There are still a large number of representatives of medical equipment. Many of them have the qualifications to practice medicine. They should take the lead in learning the latest surgical methods to be promoted. Most of the time, they should discuss the surgical plan with the doctor before the operation, then enter the operating room with the doctor, and even directly guide the doctor’s surgical methods during the operation.
Since the mid-1990s, a large number of Chinese local pharmaceutical companies represented by Yangzi River have begun to grow. In a short period of time, thousands of pharmaceutical companies have emerged in China and joined the ranks of drug competition.
The wind and cloud are beginning to change!
Domestic pharmaceutical companies entering the market have also started to set up pharmaceutical representative systems one after another. At least at the beginning, some domestic pharmaceutical companies also wanted to imitate the system of foreign pharmaceutical companies, but soon found that they could not do it at all.
The most important reason is that domestic pharmaceutical companies basically do not have the original research drugs, The drugs produced have not passed very strict clinical verification. Most of the equipment are imitations of foreign products and lack academic foundation. For a pharmaceutical company that lacks research and development capability, it is not only unable to guide doctors on the basis of evidence-based medicine, but also does not even care about clinical feedback of adverse reactions.
The other is the bottleneck of talents, The medical representatives of early foreign companies basically had medical backgrounds, However, after a large number of domestic-funded enterprises began to set up medical representative systems one after another, There are not so many people with medical backgrounds. As a result, state cadres, laid-off workers and even migrant workers who went to the city began to join the industry one after another. Soon, under the pressure of market competition, the medical representatives of these domestic enterprises quickly took the evil path of selling with gold.
The takeout gold sales refer to the illegal cash commissions given to hospitals and doctors by medical representatives in the process of promoting drugs according to their sales performance. Due to the professional characteristics of medicine itself, the sales of drugs ultimately point to doctors’ prescriptions, and the terminals of competition all point to frontline doctors.
The earliest invention of this method was proprietary Chinese medicine, Because most proprietary Chinese medicines lack clinical basis, There is no difference in curative effect between competing products, Only money can be used to open the way. At that time, Sanjiu Weitai, who was bombing advertisements on TV, In the 1990s, the commission for first-line doctors was about one dollar per box. At that time, doctors’ salaries were only a few hundred dollars per month, which was still quite attractive. After that, domestic western medicine companies quickly followed suit, quickly spread to the whole industry, and gradually formed a unique drug sales system in China.
Western medicine companies in China can only produce cheap drugs in the early days due to a general lack of research and development accumulation. In the late 1990s, some domestic pharmaceutical companies began to set foot in generic drugs just after the patent protection period. Generic drugs have no research and development costs and are priced at a similar price to the original research drugs, thus giving enterprises huge marketing space.
The kickbacks given to doctors by domestic pharmaceutical companies average between 10% and 30%. Driven by interests, It is difficult for doctors’ prescriptions not to be affected by kickbacks. Under the pressure of competition, Foreign companies also have to follow up. Foreign companies used to have clinical observation fees in the promotion process, Compliant clinical observation fee refers to the doctor’s according to the requirements of the pharmaceutical factory, Objectively record the effect and adverse reactions of patients after taking the medicine. Ten patients per page, after recording, sign the doctor’s name and give it to the medical representative, the pharmaceutical factory will settle the expenses on a monthly basis. However, after the large-scale gold sales of domestic pharmaceutical factories, the clinical observation fees of foreign companies quickly evolved into disguised drug rebates.
At the same time, foreign companies have generally improved the reception specifications for doctors to participate in various academic and marketing activities. Through soft transfer of benefits, Such as business class, Five Star Hotel, Plays before and after meetings to improve doctors’ compliance with prescriptions. In the 1990s, When the first batch of Chinese doctors went abroad to participate in academic activities under the aid of pharmaceutical factories, the authorities, big or small, were basically economy class. But by 2006 or so, a slightly larger hospital authority would no longer go abroad in non-business class. Some big medical professionals, whether private or on business, have been first class for many years, which has long been known in the industry.
In the early days, large domestic-funded pharmaceutical companies had their own medical representatives in all provinces. But some small pharmaceutical companies, Or some large pharmaceutical companies, some varieties that do not sell well, They don’t send medical representatives. In those days, the income of medical representatives was very high. It is five to ten times that of first-line doctors, and medical representatives of areas with bad markets or products with bad varieties are not willing to go. As a result, some pharmaceutical companies have handed over all the sales rights of a certain city to the well-done pharmaceutical managers in the city, completely ignoring them. This is the so-called big bag in the industry.
The purchase price of large bags is usually only 10% of the retail price. In addition to paying about 10% of taxes and 5% of logistics and distribution costs, the rest is about 30% for hospitals, 30% for doctors, 5% ~ 10% for clinical medical representatives, and about 3% for unified and daily maintenance costs. Although the remaining profit margin is not high, the sales volume is also a lot, and many large bags are easily sold in hundreds of millions every year.
Big bag this kind of wild way, Pushing the whole market to a more irrational path. Rebates to doctors under the big bag system, Up to 40%. Driven by huge benefits, Reverse elimination frequently occurs in the entire pharmaceutical market, Drugs that don’t need to be sold with gold, There is no way to survive in this market. As long as you have enough rebates, Even if there is no curative effect, It will also be sold on a special basis in the market. This has created a very strange scene in the Chinese medicine market. The best-selling drugs are often proprietary Chinese medicines and traditional Chinese medicine injections that have no curative effect at all. Industry insiders call them financialization of drugs. The functions of these products themselves have long been alienated into tools for transferring benefits through medical representatives and have no medical value.
The drug purchase price of agents was mostly about 50% of the retail price in the early days, but under the impact of the big bag system, it gradually decreased to 20% ~ 30%. Correspondingly, the proportion of drug rebates distributed to doctors is on the rise.
Under pressure, foreign companies also began to gradually [learn bad]. At the beginning of this century, most of the presidents of large foreign pharmaceutical companies in China have been localized, and the localization of corruption has also begun to accelerate. As foreign pharmaceutical companies themselves have global compliance audits, the accounts cannot reflect kickbacks to doctors, and various flexible methods have begun to be renovated.
The first way is to launder money through travel agencies. With the organization project, In the name of academic conferences, funds will be invested in travel agencies. The money is then used to pay bribes to doctors and some hospital managers. Due to lack of supervision, many regional managers will also do the same. GlaxoSmithKline is a typical case. Incidentally, that travel agency does not only provide GlaxoSmithKline, a pharmaceutical company, with money laundering channels.
The second way is for grass-roots representatives to fabricate academic conference activities. The common way is to split large-scale academic conferences into one person’s standard. Many foreign medical representatives simply buy POS machines at home, brush out the money directly, then casually find an invoice and hand it over to the company for reimbursement, and then use the cash to send it directly to doctors for [lecture fees].
As a result, the proportion of rebates given by foreign companies to doctors, It is also slowly catching up to between 10% and 15%. A U.S. Pharmaceutical company shocked the U.S. Headquarters in a year in the early 20th century when it counted more than 100,000 academic conferences held in China throughout the year. They think this figure is abnormal. If these conferences are true, it is estimated that the entire company’s pharmaceutical representatives are exhausted.
As a result, the United States headquarters proposed the establishment of a separate project, Manage academic conferences in China. However, against the background of the booming market, The plan went nowhere. Many people say that the headquarters of foreign drug companies have never been aware of corruption in China, which is not true. Although these foreign drug companies have never paid bribes in their financial statements, they have at least acquiesced in disguised sales with gold for a long time.
Around 2000, The media began to report the news of drug kickbacks. The Government has also gradually taken note of the fact that medicine represents the industry, Many domestic-funded pharmaceutical companies saw the direction of the state’s rectification of the drug market order. In order to avoid legal risks, they began to dissolve their own sales teams and the agency system began to popularize in China. Hospitals basically purchase drugs through agents. Until now, the agency system has dominated the Chinese pharmaceutical market and has formed a strong pattern of interests.
Around 2003, A senior sales official of a foreign pharmaceutical company was poached to the Shanghai district of a domestic company. At the beginning of his term in office, He hoped to introduce some academic promotion left over from foreign-funded enterprises to this domestic-funded pharmaceutical company. He spent a lot of money to invite experts to organize academic lectures for doctors in Shanghai. When he saw the scene, he immediately collapsed. All the signatures were signed by medical representatives and did not even see the shadow of a doctor.
For a while, Medical representatives active in hospitals, Between very important things, Is to help each other sign. Because business meetings require participants to have signatures, But in fact, the signatures are all medical representatives. In fact, Agents are not willing to let enterprises and doctors communicate directly, because channels are their assets. And doctors because of long-term acceptance of cash rebates from medical representatives, representatives of new faces are generally afraid to communicate easily, thus agents control the sales resources of the domestic medical market.
Between 2005 and 2006, Is the craziest time in the entire pharmaceutical industry, At this stage, a large number of drugs suddenly got batch numbers and entered the market. Competition intensifies, Marketing expenses for gold sales soared, The competition among medical representatives is also very bitter. In 2006, the government had a more severe crackdown on crazy drug rebates. All over the hospital began to put up signs forbidding medical representatives to enter. For quite some time, medical representatives did not dare to set foot in the hospital, but they would greet doctors privately and the rebate would continue to be paid. A few months later, after the wind passed, these medical representatives returned to the hospital again, and the drug rebate system was not affected.
With the intensification of competition, in order to please doctors, medical representatives have to help doctors pick up children, buy vegetables and cook in addition to cash rebates. Some even rent houses in the hospital’s family hospital to facilitate visits to doctors’ homes and can provide customer service for doctors at any time.
This kind of service competition for doctors is slowly dividing: For first-line doctors, Due to low income, more emphasis is placed on drug rebates to supplement income. On the other hand, after a decade or two of accumulation, many well-known doctors have already realized financial freedom. They are more concerned about the influence of academic circles and academic innovation. They have long despised the money of drug rebates, but their position in the discipline has also increased its influence on drug companies.
Some well-known experts, Many pharmaceutical companies send their commissioners to provide considerate services 24 hours a day, Professionally, With the support of tens of millions of scientific research and academic funds, As small as helping experts collect information, Organize PPT, Introduce the latest foreign drugs and technologies, help publish papers and so on. In life, from driving, booking air tickets, to satisfying all kinds of things, like tea, send you top tea, like calligraphy and painting, take you to meet calligraphy and painting people, meticulous. A big coffee in cardiovascular science in China, two wives are developed by medical representatives of the same foreign company.
GlaxoSmithKline incident is a turning point for foreign companies in China. Many pharmaceutical companies in China have begun to reflect on the path of the past ten years and internal supervision has begun to improve.
This is embodied in:
1) Set up a Medical Affairs Representative (MSL), which is completely decoupled from the domestic management and directly managed by the overseas headquarters. Such representatives have no sales indicators. They only talk about academic and solve some clinical problems in the process of using products when visiting, communicating and discussing with doctors. The assessment is based on the progress of doctors’ academic concepts and the number of contacts with doctors.
2) Increase the project audit of market activities, determine the academic activity standards of doctors, and control the occurrence of fictitious activities from the inside as much as possible;
3) Establish a database to monitor all payments to doctors to ensure that all payments are not linked to product sales and will not lead to prescription abuse that misleads products. However, this process does not go hand in hand. Pfizer’s Lipitor was impressively listed in the CCTV news.
However, some companies have chosen to set stricter standards. For example, GSK and BMS have announced that doctors’ travel expenses and lecture fees cannot be paid under any conditions.
But the price is also very painful.
Take GlaxoSmithKline’s new generation of antiviral drug tenofovir as an example. The original price was 1495, After negotiations by the government, the price was reduced to 497 and entered the health insurance. The government recognizes tenofovir produced by Tianjin GlaxoSmithKline as a domestic drug. However, tenofovir cannot be admitted to hospitals at all in many areas. Because tenofovir has neither admission expenses nor clinical promotion expenses. In some southwest provinces, tenofovir, which has entered hospitals, is also constantly facing the embarrassing situation of being expelled. GlaxoSmithKline’s sales growth rate in China in 2015 was-20%.
After CCTV’s exposure, The nationwide rectification movement started again, The medical representative left the hospital temporarily. At the forefront of the period, many hospitals began to reject the normal academic promotion, but the medical representative system of the whole industry still did not see signs of change. This hidden rule, which has been implemented for more than 20 years, not only polluted almost all doctors, but also formed a huge inertia.
The movement-style rectification movement is already powerless to it.
At this time, bored medical representatives gather in bars and karaokes to wait for the rectification movement to end. In a public number of the medical industry, an article teaching how to prevent government, industry, commerce and police experience is circulating among medical representatives.
Conclusion:
1. In a mature medical market, the original research drugs and surgical instruments really need academic promotion and professional support from manufacturers in the process of entering clinical practice. At the same time, the normal commercial promotion of drugs is also the work of medical representatives. However, the legal boundary is that doctors cannot be induced to prescribe through interests.
2. In China, due to the general lack of academic foundation and poor supervision of domestic pharmaceutical enterprises, a common gold-bearing sales model has been formed. Pharmaceutical representatives have gradually become intermediaries to bribe doctors and hospital managers, and this system is still the mainstream of the pharmaceutical market.
3. Sales with gold alienated doctors’ prescription behavior, distorted the reward system of the market, and finally worsened the doctor-patient relationship. However, the movement rectification movement did not touch this system.