As with other parts of the sales model, companies need to test whether training moves the needle on outputs. While deploying fewer but smarter, more strategic reps seems like a logical next step, at the end of the day, if it doesn't up prescribing, why make the effort? "There's no ensuring that seasoned, very educated reps are having more sophisticated dialogue that is going to translate into more time with the primary care physicians," says O'Grady of Campbell Alliance. In this way, O'Grady points to the limitations of the primary care office to accommodate pharma's strategy for increasing value. "The providers have only so much time to interact with reps. So your rep that can do a deeper discussion of ancillary care and the care continuum may not offer any benefit over a rep that is delivering a basic core message and samples if both reps are getting less than two minutes."

Think Local

Managed markets have been putting the squeeze on pharma's sales model by hitting patients with co-pays at the pharmacy counter that are high enough to make them rethink their brand choice. In response, companies have focused their efforts on proving the value of their drugs to medical directors at managed care organizations through pharmacoeconomic studies as well as offering service packages that increase wellness and compliance. But surprisingly, there is nothing really new here—pharma has been using these tactics for years. "With managed care field forces or marketing, it seems to have gravitated toward 'It's all about price,'" says Gerard.

Indeed, much of Pfizer's stated realignment of sales with managed markets is thought to exploit this niche. "Pfizer is probably cutting their sales force disproportionately where managed care is either restricting their access to physicians, which is a real problem in some parts of the country, like the Pacific Northwest and California," says Amundsen Group's Tenaglia. "It could also mean they are adjusting their sales force downward where they have restricted formulary access. That's a very sophisticated view of the world, but if anyone can build in that sophistication, it's Pfizer."

In addition to the access issue, many companies are realizing that running a sales force at the national level in this new reality is neither effective nor efficient. Given the variability of regions in terms of payer mix and formulary status—not to mention regulations of per-doctor spending caps and practice guidelines—firms are eyeballing a shift to a more on-the-ground approach. "There are wide geographic differences, and physicians have to practice within them," says Nancy Lurker, senior vice president and chief marketing officer at Novartis. "At the corporate level, we're never going to know with the same granularity what the regional managed-markets person is going to know."

In many ways, this moves the responsibility and accountability for sales down the line, to regional sales managers and even reps. "Some say, 'We've got to treat these sales people like they're business managers,'" says TargetRx's Luby. "We're not going to tell them they have to make eight calls a day or who they have to call on and when. We're going to tell them, 'In line with regulation, do what you need to do to make sure you can deliver the sales out of your territory.'"