4

Raise the Stakes

1993

DUXBURY grew into the challenge of selling Procrit. He didn’t believe in the hard-sell approach, never had, and thought that salespeople in general got bad reputations because of a few dishonest ones. He wasn’t indifferent to the monetary rewards and trophies that came with the job—far from it. He craved the attention and prestige that followed a top-tier rep. Yet, like most successful salespeople, he was driven by something bigger than personal gain. To him, making a Procrit sale meant that he had helped a patient by introducing her to an efficacious, vivifying medicine. A sale also signified that he had forged an authentic connection with another person, a buyer, which was no small thing when you’re an itinerant worker. His philosophy was that if he could help patients and make a client look good, he’d eventually land the account. His clients became his friends, and what kind of a guy screws his friends for a living? “When done right, sales can be a wonderful experience.”

His sanguine view was noticed by those he met on his daily rounds. One such person was an attractive, light-skinned black woman named Renee Matson, and for the past year or so, they’d grown especially friendly. The two had met a few years earlier when they were selling cardiovascular drugs, he for Bristol-Myers Squibb and she for Merck. The rivals would bump into each other on sales calls and quickly took to teasing one another with their rapier wits. Matson found Duxbury so lighthearted she was sure he was a happily married man. Around her, Duxbury felt like kindling in the presence of a spark. One day, he finally screwed up the courage to ask her out, and she quickly agreed. Beneath his easygoing demeanor, she saw a driving ambition, and the two began dating. They made a striking mixed-race couple, he with his heart-shaped face and flaxen mustache; she with her café-au-lait complexion and short raven hair. In early 1993, he proposed marriage, but she wasn’t ready. Undeterred, Duxbury kept sparking her with his cheery, earnest courtship.

He loved the thrill of the chase, whether pursuing love or money. To him, the pharmaceutical profession was like a coliseum filled with charioteers and gladiators. Sales reps worked under harsh conditions, tolerated jeers and rejection, and strove to not simply survive the obstacles but surmount them with flair. A few wound up inspiring admiration and even acclaim, and Duxbury studied them. Every week, he received from Raritan a colorful play-by-play description of the latest joust or deal. He kept abreast of the national sales statistics, individual rankings, and weekly competitions. Sometimes the cheese was spread a little thick, as in the latest contest, for example. It was named after a popular television series called Murder, She Wrote, only instead of spinning tales about murder cases, Ortho reps had to sway doctors to write more prescriptions. In J&J’s version of the game, “Procrit They Wrote,” Duxbury already commanded a lead. He’d sold enough medicine to earn a coffee mug, was about to collect a videocassette movie (starring Angela Lansbury), and just might win a box of gourmet meats, called the Steak-Out. The grand prize: a London Fog trench coat.

Duxbury periodically flew back to New Jersey for more training. Traveling from his Seattle home to J&J’s headquarters amounted to an eleven-hour day, including the three-hour time difference. At one point, he was called to a diversity-training seminar that reviewed company policy on racial discrimination and sexual harassment. Duxbury believed he was among the least racist, least chauvinistic men on earth; he’d been raised by a working mom and was dating a black woman. Even so, in February 1993, Ortho insisted that all employees attend the class. So Duxbury boarded a plane to New York City on the same weekend in which a bomb exploded beneath the World Trade Center in Manhattan. The incident had triggered a massive manhunt, clogged Eastern transportation routes, and delayed his flights.

While stranded in an airport, he called Renee. “I miss you,” he said.

“Me too,” she replied. Then she paused, uncertain how to deliver the news. So she blurted it out. “I’m pregnant.”

Duxbury was elated, and Renee seemed happy too. He proposed to her again, and this time, she accepted. They cooed and jabbered until his flight was about to board. As he walked toward his departure gate, he yearned to be heading west rather than east. By the time he arrived in class early Monday morning, he was sleep-deprived and resentful. He listened to the teacher point out historical events in an effort to underscore how white men were responsible for things that the students themselves had not done. Yet any criticism of affirmative action programs was barred; Duxbury felt a subtle form of reverse discrimination. “We could be a rat species, the way the instructor is talking about white males,” he thought.

He wanted to object but instead bit his tongue. After the session, he bluntly told the teacher, “You’ll never convince me that this class was worthwhile.”

Duxbury’s disdain of the politically correct environment in which he operated would boomerang against him one day.

IN early 1993, it was time for managers to hand out new sales forecasts. Duxbury opened his mail and braced himself. He figured his new target was about to skip 20 percent from $250,000 a year to $300,000—which would be a hefty jump. Yet, when he saw his new figure, he nearly choked. His goal had quadrupled to $1.1 million. He immediately called his boss. “I have virtually all of the nondialysis business in my territory,” said Duxbury. “What more do you want?”

“Mark,” Nelson responded, “I hired you because you were supposed to be a hotshot. But I’m not getting my money’s worth.”

Duxbury’s mouth snapped shut, while the rest of him objected strenuously. As his leg jackhammered and his nostrils flared, he made some mental calculations. One of his best clients was a doctor’s office that bought $4,000 worth of nondialysis drugs every month. Duxbury could make five such sales a month for $20,000. That’s how he had made his 1992 sales goal of $250,000. Only, now, he had to sell $100,000 a month, a mind-boggling amount. “It can’t be done,” he told his boss. “There isn’t that much business in my territory.”

Nelson didn’t want to hear that. But over the next few days, Duxbury talked to a few reps scattered in other cities. McClellan’s forecast had doubled to about $600,000, and others had gotten fat increases too. But he couldn’t find any other person who’d been saddled with a 400 percent increase. “My forecast is one of the largest increases in the nation,” he realized.

In a way, it was flattering. “They must think a lot of you to give you such a big goal,” McClellan told him. But Duxbury didn’t see it like that. More likely was that someone in headquarters had made a mistake. The rep could help correct the error by breaking out the actual amount of nondialysis patients in his turf. He slowly began to collect those figures from his clients, certain his target would be readjusted.

In the meantime, he continued making his calls. A Wenatchee-based clinic bought $30,000 worth of Procrit a year for prerenal failure and AIDS, a measly $2,500 a month. St. Joseph Hospital purchased Procrit for its HIV patients, but the amounts were minuscule. In fact, few hospitals in his territory had much of a nondialysis sector at all.

In the meantime, his bosses asked him to estimate the total dialysis sales in his district. Since his compensation would be affected by these numbers, he decided to compile not just the dialysis figures but his rightful nondialysis ones too. It took several weeks, but in spring, Duxbury wrote a friendly memo to his boss and his boss’s boss, William Ball. Here’s the total estimated dialysis business in my territory—$3.45 million. He compared that to the total epo sales in his territory, $4 million. “That leaves me with roughly $500,000 in nondialysis business,” he said.

So why, he asked, was he being saddled with a forecast of $1.1 million—double the amount of business that legally belonged to him?

His bosses said they’d take these figures to Amick.

IN Raritan, meanwhile, a manager came across a shocking request. Two veterinarians had submitted Procrit invoices proving they’d purchased large amounts of the drug. Now the vets, one in California and the other in Georgia, wanted their 8 percent rebates from Ortho’s popular Physicians Rebate Program.

Epo was becoming so established that dog and horse owners not only knew about the drug; they were doping up their animals to gain the racer’s edge. Yet animals injected with even low doses of human epo showed signs of distress: a greyhound’s natural ability to produce his own red blood cells crashed, leaving him severely anemic; a horse’s blood turned to sludge, setting him up for pulmonary embolisms; some Thoroughbreds received such an epo “rush,” they ran themselves to death, collapsing in heaps of sweaty flesh.

By 1993, researchers at Cornell and Rutgers Universities had begun to devise animal doping tests to stop such blatant abuse. Others mounted clinical trials to find safer versions of epo to help chronically ill pets. Yet still no word about the safety trials from the makers of Procrit, Eprex, or Epogen. Could it be that veterinarians had better information about the drug than doctors who treated humans?

PROCRIT vials began to move nationwide. Salespeople in not just Bennie Thompson’s division in Florida, but Louisville, Kentucky; Topeka, Kansas; Asheville, North Carolina; Visalia, California; Burlington, Vermont; and Boston began converting Amgen customers to Procrit. Thanks to Ortho’s supplier, Charise Charles, some offices started making their high forecasts.

As for Duxbury, he kept hammering away at St. Joseph, a “mixed-use” institution with both dialysis and nondialysis beds. Designed by the daring Chicago architect Bertrand Goldberg, the building incorporated geometric whimsy and space-planning concepts that helped make it an efficient institution. Duxbury could spot its circular tower from miles away, rising above Tacoma like a giant honeycomb.

He had cultivated a nice relationship there with a renal pharmacist named Robert Dimino, and one day, Dimino told Duxbury that St. Joe was in the process of developing a centralized pharmacy research unit. Among other things, the druggist hoped that his pharmacy would have the capability someday to run statistics on the hospital’s patients, their medicines, and the pharmacy’s expenses. “We don’t have the type of equipment to do those things right now,” Dimino confided.

“What do you need?” Duxbury asked.

“For starters, we could use a computer.”

“Let me buy you one.”

Dimino balked. No drug rep had ever made him such an offer.

But gift giving was commonplace at Ortho. Every district had several pools of cash that were earmarked for meals, events, and other offerings to clients. A regional director could dole out several $10,000 “educational” grants a year, dozens of luncheons for nurses, or a few lavish dinner “programs” for influential Procrit customers. The directors had a lot of discretion, but all of the grant checks were issued from Raritan, so Duxbury assumed they were legitimate.

Even so, Dimino reacted as if Duxbury had offered him a bribe.

“C’mon, Bob,” Duxbury responded. “I’m not asking you to marry me. I just want to do a little business with you.” The pharmacist said he’d check with his superiors.

Later, Duxbury told Nelson that they should “facilitate” St. Joe’s purchase of a computer system. “It’ll help us establish a good business relationship.” Nelson, however, needed to justify the expense. He suggested that if Dimino would conduct some loosely defined “trial research” on Procrit, Ortho could buy him a computer. So, one January day, Duxbury took Dimino to lunch at a fine restaurant. After the two had placed their orders, Duxbury slid a check across the white-clothed table. “This’ll help you establish a database at the pharmacy,” he told his guest. “It’s enough to buy a computer, some software, and whatever else you need.”

The pharmacist looked at the $10,000 check and stammered. Duxbury assured him the check implied no obligation. “It’s a symbol of our commitment to building a long-term, mutually beneficial relationship with St. Joe’s.” By federal law, large gifts tied to drugs that are paid for by Medicare are verboten, but a loophole allowed hospitals to accept money for research and “continuing education.” But before Dimino could accept this substantial sum, he’d need to check with his boss, Al Linggi. After a few weeks, the hospital’s managers decided to keep the “charitable gift,” and from then on, Duxbury found himself warmly welcomed inside the efficient hive of St. Joseph.

As spring rolled on, Duxbury felt the pressure to sell. He and Renee had married and were living in her house a few blocks from the railroad tracks and the Tacoma Narrows Bridge. Since the couple was expecting a child, they had talked about Renee’s quitting her job to stay at home with the baby. But in order to support his family in style, Duxbury would have to double his income and make at least six figures. It wasn’t like he craved to be a master of the universe; he just wanted to be lord of his own two-car-garage manor, with a backyard barbecue.

He still hadn’t received any word about his ridiculously inflated target, but he wasn’t the only one complaining about the hefty numbers. Of Ortho’s four national divisions, the Western Region seemed to be disproportionately affected by expectations, and another one of Ball’s managers had just written him. “It’s very frustrating,” the manager complained. “When you look at [our forecast] figures, it is quite evident that they don’t truly reflect the nondialysis market for epo.” Ball shared his troops’ frustrations. He collected these field dispatches, including Duxbury’s memo, and sent them to Raritan, again requesting a more reasonable target for his district.

But Amick was unimpressed by the reports. To him, the moaning and groaning was the sound of salespeople trying to wiggle out of some hard work. He told Ball that if he wanted his target to shrink, he’d have to find “irrefutable evidence” from a third-party source that Amick’s goals were unrealistic. Otherwise, he told Ball to work with what was in front of him.

Every industry has its form of intelligence, a way to gain an advantage by obtaining private or secret information without the permission of those involved. For pharmaceuticals, one especially sharp tool was the Drug Distribution Data, which held a gold mine of personal information. Doctors and patients like to think that the details about their personal prescriptions are private, but the truth is that nearly every pill and injection purchased by the nation’s hospitals, pharmacies, and doctors shows up in reports. These accounts mine data from insurers, wholesalers, drugstore chains, HMOs, the government, and the American Medical Association. In the early 1990s, these institutions began peddling their information to commercial clearinghouses like the giant IMS Health, and they in turn sold the intimate facts to Merck, Pfizer, and other pharmaceuticals, charging hundreds of millions of dollars a year. DDD reports, for example, allowed Ortho to pinpoint exactly where epo was being used, and which clinics were living up to their purchase commitments. Although sometimes you couldn’t see the names of either patient or doctor in these reports, it was easy to identity a prescriber based on his ID number issued by the Drug Enforcement Administration.

Yet most doctors in 1993 had no clue that traveling reps knew more about their drug-prescribing habits than they did, and that fact alone gave a salesperson a huge psychological advantage. A doctor might think he was writing a hundred scripts a month for a certain medicine simply because of its merits, but maybe that $7,000 rebate check or the $10,000 “grant” had helped. Savvy pharmaceutical managers could actually link the timing of a gift with the subsequent placing of an order, and that told reps like Duxbury what sort of “marketing plan” worked best with certain clients. “If doctors knew that every drug they’d prescribed had been tracked, they’d go ballistic,” McClellan once told Duxbury, and he agreed. That’s why these drug reports were marked confidential. In fact, secrecy was such an integral part of them that IMS contracts specified that firms had to keep the physicians’ data hidden from the doctors themselves. At the bottom of each DDD page was a warning: “This information . . . is confidential and is not to be disclosed. . . .”

Ball used this espionage tool to bolster his case for lowering his region’s forecast. The DDD reports recorded the actual epo sales in his region—and in Duxbury’s territory. The problem was that there was too much information: one had to chunk the drug sales by state, territory, and zip code; or by week, month, or quarter; or by any number of different ways. Ball had ordered the epo sales data, and when he received the six-hundred-plus pages of material, he had to analyze it. For that mind-numbing job, he and Ortho hired yet another middleman in the health-care pipeline—a high-priced consulting firm, which agreed to define Procrit’s market in the Pacific Northwest.

Two months later, the consultants delivered their report, and in June 1993, Nelson summarized the results for Ball. Duxbury received a copy of that letter, too, and now, sitting in his office chair, he readjusted his spectacles to read it. There was “absolutely no doubt that greater than 90 percent of the dialysis market had been treated as nondialysis,” Nelson wrote; Duxbury felt like rejoicing. But then Nelson hedged. He had identified specific retail customers, which, “if converted, would dramatically impact [Duxbury’s] retail market share.” This seemed contradictory, so Duxbury turned to the DDD report itself and found some serious problems. For one, it included in his territory a warehouse that housed $300,000 worth of epo—and nothing else. “That facility shouldn’t even be part of my forecast!” But according to the high-priced consultants, it should be and added $300,000 to his forecast.

Duxbury called Ball and relayed this and other mistakes he had found. Ball listened sympathetically. But they had to wait for Amick’s verdict.

Meanwhile, Nelson grew anxious with so much clandestine data floating around. All copies of the epo market reports had to be destroyed, but discreetly. “Whatever you do, Mark, don’t throw those DDD books away,” Nelson warned. “Amgen might pick those books out from our garbage.” Corporate gumshoes rummaging through a rival’s trash seemed like the stuff of spy movies. But the pharmaceutical industry, with its lucrative proprietary products, had grown skilled in the ways of skulduggery. Amgen itself had been the target of biotech’s first “sting” operation in 1988 after an ex-employee had tried to sell the confidential formula for epo. Since then, Amgen, J&J, and other drug companies had installed ever more sophisticated surveillance systems, employing former FBI executives, foreign agents, and black-ops experts to guard their treasures from competitors and counterfeiters. That’s why Nelson was nervous about being caught with reports that listed Epogen’s sales. Fortunately, he had recently purchased a shredder for his office, which in 1993 was a rare sight. He collected the DDD reports from Duxbury and fed them through his machine. As Nelson ripped the lists of epo sales into strings of confetti, Ball sent Amick “irrefutable evidence” from the third-party consultant that the Western Region’s numbers were off. Then, he waited.

Around the same time, yet another Western Regional meeting took place, this time in sunny San Diego. One afternoon, Duxbury and McClellan joined an expedition to Torrey Pines Golf Course, which bordered a natural reserve that was home to skunks, raccoons, and the dramatic-looking Torrey pine trees. The reps were joined by a few Ortho executives, including Tom Amick, and the party set out to play atop windswept cliffs. They were followed by a cart carrying a few young, pretty women who dispensed cold beers to the sweaty players. The game turned rowdy, and after an hour or so, Duxbury felt so relaxed, he turned to Amick and broached the subject that was on everyone’s mind.

“Boy! This year’s sales forecasts sure are brutal!” A few of the reps nearly choked on their beer; the managers leaned in to hear the vice president’s reply.

“Get used to it,” Amick snapped. “The forecasts aren’t changing.”

Duxbury stood back and let Amick take his shot. Then the group walked along the cliffs to the next hole, where wind-whipped trees looked as if they were about to fly. Duxbury and McClellan fell behind the group.

“Well, at least I know where the big guy stands,” Duxbury said.

Duxbury had just started to adjust to the idea that his forecast would remain when, a few weeks later, he was thrown off course. Amick had not only refused Ball’s plea to lower his region’s numbers; he had actually increased them. That, in turn, had pushed Duxbury’s forecast up 50 percent higher to $1.6 million.

One million six hundred thousand! That was five-and-a-half times more than what he had sold last year. Duxbury was so angry, he couldn’t see straight. His wife grew agitated too. With their firstborn due in ten weeks, the rep now had six months to make what seemed like an impossible quota. He met with Ball and Nelson and pleaded in person. But Ball threw up his hands. “In order to correct this, Mark, I’d have to take money out of your goal and put it onto someone else’s. I don’t want to do that.”

Duxbury knew that any further argument would amount to little more than a shoe-gazing exercise. Still, he warned his bosses, “The only way I can meet this quota is to steal dialysis business.” Then it dawned on him: Robbery had been the point all along.

THAT summer, St. Joseph’s epo contract with Amgen came up for renewal, and Duxbury moved in. He sensed that Amgen over the years hadn’t given its top client much of a discount, especially considering the large amount of epo St. Joe purchased. He doubted if Amgen had ever given its client a rebate or a grant. But Duxbury had been wooing St. Joe’s administrative director of pharmacy services, Al Linggi, for months, holding out those perks as an incentive to buy. One day, the rep again suggested that St. Joe could actually make money buying Procrit. Perhaps that should be factored into the hospital’s decision.

Linggi considered that. “If the safety and therapeutic value of the two products are identical, I guess the determining factor would be economic,” he admitted.

“So, if Ortho’s product is identical to Amgen’s, your decision comes down to finances, is that what you’re saying?” Duxbury asked.

The druggist nodded and let the implications spill like pills across his desk.

Duxbury took the hint. “What if I gave you a significant discount on the product?”

“Then we could talk.”

Duxbury couldn’t slash prices without his boss’s approval. But he had just secured the business of his future client. “I won’t take up any more of your time,” he said. “But I’ll call you in a few days with a proposal.”

Indeed, Duxbury and Nelson called on Linggi and presented Ortho’s best deal. If the hospital placed a $250,000 order, it would receive an 8 percent discount. If it bought $500,000, it’d get a 9 percent discount. And if St. Joseph placed its entire $1.4 million order with Ortho, it would get the best package of all: a 14 percent discount off the AWP.

Amgen’s rep had already submitted a bid, but the pharmacist looked Ortho’s over and said he’d present Duxbury’s proposal to his committee. A few days later, Amgen’s rep returned to Linggi and learned of Duxbury’s presentation. He offered to meet whatever price Ortho had offered. By then, however, it was too late; Linggi had seen in black and white the many advantages Ortho gave clients. When Duxbury called on Linggi later, the pharmacist warmly invited him in. “We’re going along with the group,” he said. Duxbury didn’t understand and waited, perspiring under his designer jacket. Linggi added, “We’re accepting your bid, Mark.”

A wave of relief flooded the rep.

That summer, six months after Duxbury had given St. Joe a $10,000 check, the hospital switched its epo account from Amgen to Ortho. The initial order was only for $250,000, but Duxbury sensed this account would grow. In his Northwest territory, Procrit began to catch up to Epogen, and Duxbury’s reputation grew.