If a physician has a large patient population in an HMO with a strict formulary-adherence policy, reps need to understand how this may affect the physician's prescribing. For instance, if the rep's product has a prior authorization, and it is time consuming for the physician to write an alternative product, the rep may never get—or even need—a chance to compare the efficacy and safety of her product to that competitor. A three-dimensional view of this selling environment must take account of formulary availability, including the plans your respective customers participate in and the percentage of patients represented in each plan—and finally, how these plans influence the physician or his/her office staff. All of these elements together will help the sales representative identify and reach the most responsive targets.

Just look at the following example: My wife is an internal medicine physician. Her clinic administrator once asked her how she treated asthmatic patients. Her reply reflected her minimalist, common-sense approach, which invites patient participation in the treatment and medication plan. She relied on patients to tell her how they felt and how well they responded to medication. When the administrator wanted to know how often she performed a certain test, she said that she ordered it only when the patient was non-responsive to the prescribed treatment and medication plan. The administrator suggested that she (my wife) should order the test every six months, because that's how often the practice could bill for it.

Some physicians cave to the financial pressures to order unnecessary tests, while others prefer to cite data supporting their position. Understanding the pressures on a physician may help a sales representative to position products within that doctor's practice. A rep with an asthma medication may be able to help the doctor by providing data to support a minimalist approach.

As a hospital sales representative, I mapped the relationships that were important to each physician on something I called a "spider diagram." The diagram charted relationships like these: I once played poker with an urgent-care doctor who introduced me to one of my hard-to-see internal medicine physicians. He, in turn, introduced me to another hard-to-see internist, with whom I later trained to run a marathon. So I had four hours of one-on-one time every week with a no-see doctor because I leveraged a cascade of relationships. In addition, I met a new friend who, in turn, expanded my network even further. Using a spider diagram to show how doctors relate to each other and the world around them helps reps identify key doctors without using specific prescribing information. This does not require inappropriate influence. The rep simply gets to know the doctor, maps the doctor's interaction with the environment, and shares specific product-related information for the doctor to objectively consider. Mapping enables reps to incorporate new levels of insight in order to better share information. Analyzing these relationships helps the sales representative build a complete picture of the customer, both within and outside the unique medical setting (see "A Sales Rep's Tangled Web,").

The Road Forward

It would not be easy for a vast number of sales representatives to apply account-based selling strategies in the community setting. However, every sales representative may have to do this if prescriber-level data is no longer available. The data they obtain by qualifying physicians, understanding the impact of health plans, and mapping the relationships of prescribers will enable them to succeed without modern databases. It's hard but it is not impossible.

The sales representative is not the only one who will have to change. The entire organization will need to retool. Sales training departments will have to teach business acumen and explain how account selling works in community settings. Sales management may lack the experience or skills to advise direct reports on how to use these techniques. Operational departments may need to develop new ways of recommending targets to field management and sales representatives without communicating prescribing information. For this to succeed, however, the sales force needs to trust in operations. The proverbial "the data is wrong" argument will take up valuable selling time and attention, especially if the sales representative is unable to confirm or deny this information through the successful implementation of account-selling techniques.