Field Force Fluency

In this exclusive video, Steve Daniel of Campbell Alliance gives us tips on how to ensure your field force can demonstrate fluency with your customers.

Video Transcript

Steve Daniel: My name is Steve Daniel with Campbell Alliance. My background, just real briefly, is I was a sales rep for a number of years with Allergan. Did a little bit of sales training as well and then got my MBA at Rutgers and came to Campbell a little over 6 years ago and been working on a variety of different consulting projects and pressing market access, training, sales strategy, brand marketing. So kind of a broad set–looking for my clicker. So today we’re going to talk about Market Access Fluency. And really the key questions that we’re going to address today are, you know, why is it gaining so much attention? Why is it generating so much attention in the marketplace and I think, you know, if you pick up the paper, you know, search the internet, watch the news on TV or even just talking to your friends, you can quickly understand what’s evolving and changing in the marketplace. We’re also going to talk about what actually is market access in the context of kind of the customer facing team role because that has a lot of definitions as well. And we’re going to talk about fluency and why it’s so critical. We’ll talk briefly about how you build that fluency or at least what it looks like in the organizations. So why is this generating so much attention? And there is a recent report out from Bloomberg about 2 months ago and it was based off of the whose data and when you look at the spending per capita by country, the US is actually number 2 in the world. So most of you thought we were number 1. We’re actually behind Switzerland and it accounts for 17.2% of or GDP. So it’s a huge spend and it’s costing US a lot of money. And this is actually more why this is generating so much attention. So when you look at–this is some of the research that we’ve done but again, in that same Bloomberg report, there was a lot of corroborating evidence that the US spends a lot of money but we don’t really get a lot for what we spend. So from an efficiency standpoint, when you look at metrics such as life expectancy and things like that, we’re ranked very low.

So in the Bloomberg report, we were 46/48. We did beat out Serbia and Brazil, so that was good news, but the challenge is how do we get better value for the dollars that we’re spending? And then also maybe find opportunities to reduce some of that spend as it’s becoming quite a burden on the marketplace. So enter Healthcare Reform, and this is just kind of one snapshot of it but, you know, the government is back open again, so that’s good news. Hopefully, they’ll solve this problem. I don’t have too high hopes but Healthcare Reform is fundamentally changing our business models in pharma and our customer’s business models. People are organizing differently, so this is just kind of a little glimpse into how some of the ACOs or we call them organized customers because ACO is really a Medicare program, a pilot program where they’re looking at coordinated care and changing the way healthcare providers are compensated, how they coordinate care to get better outcomes but commercial payers, health systems, integrated delivery networks. They’re all exploring different things to basically get better outcomes for their patients. Better quality and somehow reduce cost so they can either share in that savings or reduce some of their losses. So when you look across the country, obviously a heavy concentration on the East Coast but it is scattered throughout and this is just, you know, one representation of some of the multi-payer ACOs and some of the private single-payer ACOs but payment models are changing, fee for service is being reduced and it’s–we’re moving more towards an outcomes based. So I know these are all different topics that your companies are wrestling with right now, I’m looking at–but this is really what’s driving it, money. Healthcare Reform really a–two thrust. One was to expand a pool of people that have access to care, so starting next year, you know, if they get the health exchanges up and running and people can actually register, they’re expecting about 30 million people who currently did not have healthcare coverage to have healthcare coverage. And that’s going to cost a lot of money, so looking at ways to manage those cost. So what is market access? And I put market there because when you talk to different companies, access could be getting into talk to the physician, it could be a lot of different things. So I want to talk about in a context of access for patient’s healthcare providers. Other people–other stakeholders in the healthcare environment to get access to treatments and medications for ultimately the patients. So there is patient access to care, there is the affordability aspect for the patient. There is–what some of the payers are doing to actively manage and control those costs and then there is protocol and guidelines that are also are means to get–to control some of that as well. So let’s talk about patient access to care. So I mentioned that next year we’re expecting this bolus of new patients that certainly accessing healthcare previously or to as an extent that they couldn’t because they weren’t covered coming into the healthcare environment and what we’re seeing is a huge trend for reduction in the number of sights of care. So hospitals are buying up physician practices and this is kind of a little bit oncology focused but the same trend is happening with PCPs and Cardiologist and another specialty groups where it’s going to be harder to find a place to get your care as a patient. And when you look at the news as well, there are reports where we just don’t have enough doctors. How are we going to solve that?

So access to care is going to become a challenge for the patients but what that’s going to do to our customers is we’re calling on physicians and institutions is really strain them. It’s going to put a lot of extra pressure. They’re going to be seeing more patients trying to manage those patients. Still get the outcomes with reimbursements going down but just how we’re going to take care of these patients.

Patient affordability. There’s really two aspects to the affordability for patients. There is the premiums and those kind of the out of pocket costs. So when you look at the premiums and from 2002 to 2012, we’ve seen a significant expansion. I am sure each of you have seen, you know, the amount of money that comes out of your paycheck going towards your healthcare for yourself or for your family has been increasing. Well, behind the scenes and what’s changing that number also is employers are sharing a huge part of that cost. So you can see overall, you see over 50% growth in the cost of premiums to the whole patients. That’s one patient or their family unit. $8,000 going up to 15 and the employers are taking a huge burden of that but we’re also starting to feel on the worker side as well with nearly a 40% increase in our premiums. The other way that cost shifting is coming over to the patient is through copays, out of pocket expenses, so co-insurance or copay. And you can see over that same tenure period a significant, almost 60% increase in the 3rd to your copayments and I remember back when HMOs first started it was, you know, $2 for a prescription or as any–everything was on formula. There was no issues and gradually over time, you know, then you had the $5, $10, $15 copays. Now you’re 3rd to your copay $50, $75 or specialty tiers, the cost has been skyrocketing for patients and it’s a lot to manage and that’s one way drive people to certain treatments and I know we all struggle with that with our branded products trying to figure out how we can get these to patients and the physicians’ offices are seeing it to and that’s, you know, a lot of the conversations. So I agree completely with Tom that, you know, the number one job of the representative is first to sell the products so the clinical benefit and the safety profile, the tolerability that’s what’s going to make the physician want to write it. That’s what’s going to make the patient want to take it because they want to get better but more and more as cost rise it’s can I afford this? And how do I manage that? So the conversations with physicians and their offices ultimately are getting blended into this, both clinical and cost conversation. So I want to talk a little bit about active benefit management and this impacts different pharmaceuticals whether they’re infusible or oral and it really depends on your therapeutic area but this is an example of a Step Edit in diabetes, so basically for those of you who don’t know, Step Edit is basically something that when you go to fill your prescription as a patient, if it’s not on this path, so to speak, if it’s not I did this first, you can’t fill that prescription. The pharmacy will not fill it. So in this case, BlueCross BlueShield said metformin which is a generic product, its been out for a long time, used as one of the first line treatment once people go into pharmaceutical management of their diabetes, has to be used first. You can’t just jump to a new branded product. Then after that, the patient has to fill on Byetta, that’s preferred. So there is different agreements that the managed care company may have with the makers of Byetta to, you know, get rebates and may have also looked to the clinical efficacy and they’re basically saying here is the steps you need to take. You can overcome this. As the physician’s office, they can file a claim of medical necessity. It’s a lot of administration, there’s a lot of work there and it’s not always successful, so typically you’ll just kind of go through the steps. Where that leaves the patient is maybe not on the optimal treatment and delaying that treatment and this is what managed care companies are doing more and more is they’re creating these steps and boxing out certain products that may be very beneficial and even better for certain patients if you don’t go through this step wise process. And the rationale behind it is they’ve looked at the data and they feel that this is the most efficacious and cost effective approach for their patient base. There is even double step at it when you look at some oncology products and things. So this creates this lack of confidence in physicians’ offices if you have a Step Edit on your product.

Even if it’s with one managed care company, they’re just wondering is this going to get covered. And they may go through this path and not use your product as often as you might like them to. So it’s–as a managed care–a pharmaceutical sales rep going in there if you have a Step Edit on your product it’s helping the office manage through that and help them understand how they can get the product in a timely manner for their patients that they feel is clinically necessary and appropriate and how they can navigate around that.

Medical policy. These are not for every product. Very common with infusible products, oncology, rheumatology and what this is, is the–if you will an instruction book they could be very, very long and a lot of physicians don’t know if a payer has one, they don’t know what is says. And it’s very specific. So this is from Regence, it’s an oncology product, and basically this tells you when you can use this product. What the dosing is, how long you can use it, you know, you have to do this and this and that. Sometimes it’s actually hard to find these. We were able to grab this off the websites, so it’s a lot for a physician and their offices to monitor this. Know when these medical policies come out. They don’t publicize these widely when they do come out. So and again, these offices see multiple patients with different insurances. This is just one of the insurance plans that has it but it start shaping how physicians view your product and it becomes a challenge and those conversations need to be had in the office with the staff with the physicians. So yes, we’ve sold the clinical relevance. Now, how do we get the product to your patient or what’s the patient covered under? What are the steps that we need to take?

And lastly protocol guideline status. This is most popular in oncology right now but you’re seeing elements of it. Clinical policy is kind of like that, you know, the certain way–guidelines which are just guideline for cardiology, for diabetes, for HIV and the other published by different medical organizations. There is really no teeth in those. They’re just guidelines. They’re certainly a good review of the medical literature and you know help to guide physicians in their decision making but what these protocols are pathways for oncology is really the approach, the instruction manual for physicians. So if a practice of an institution adopts these, that becomes how you treat a specific disease. This is what products you use, when you use them and what order? How you may sequence them, what the dosing is and really their design is ultimately, again, there is a lot of reviews in the medical literature and they believe the clinical evidence of P4 is one of the guideline developers. It’s a third party company that can be hired. They’re trying to just narrow things down and what it does is it help to sell their services to either the institutions or the payers to help reduce cost. They review the literature, see what generally has the best outcomes and that’s what they’re trying to drive people towards. They’re trying to reduce the unpredictability of different treatments. Again, we can only promote on label but physicians can write the products for whatever indication they want and some of these medications are very expensive. So as a payer, you don’t want to necessarily restrict access to the medication that could benefit patients but if you’re not very confident that it’s going to really help them then how do you manage that without upsetting your network too much. You create these pathways, so it helps them to understand what is clinically relevant and helps them to reduce their utilization variability and ultimately it actually helps the office or this is how they, you know, talk about it with them because if it’s on the pathway, the office is pretty confident they’re not going to have to submit prior authorizations. They’re not going to have to worry about Step Edits. They’re not going to have to worry about different formulary restrictions. They’re going to get reimbursed if it’s a buy and build type drug.

So this is a very attracted to something that’s gaining a lot traction and I think, you know, you might see some of this approach being taken in the ACO model where they’re trying to manage their costs. And they’re trying to reduce the unpredictability and standardize how patients were treated across their hospitals, their practices and their specialists. So protocol guideline status is a very big area that certainly oncology companies are looking at but a lot of other organizations are starting to look and kind of figure out and again the ACOs or organized customers are also looking at these as potential ways to reduce their cost and control some of the predictability of outcomes.

So what is access fluency? And really we defined it as the ability to leverage the common language of market access and reimbursement and incorporate that into your strategic planning. Coordinating across your team so earlier some people have talked about all these different customer facing roles. You know, you have reimbursement specialists, you have MSLs, you have representatives of different flavors, institutional community, you know, there’s the key accountant managers and that’s a lot to coordinate and then ultimately provide solutions that support the access to your company’s products for both the decision maker which is the–usually the healthcare provider and then ultimately the patient who actually is really the ultimate decision maker. Are they going to take this medication? Can they afford this? And why it’s so critical is all that we talked about before, all these market forces, the cost pressures, the changing of the business models and how physicians are being paid or joining hospitals and now they are paid employee versus running their own business. They have a lot of questions. Here it’s just kind of three and they’re wondering, you know, the treatment that I choose is my patient actually going to get or this is going to be switched to the pharmacy, am I going to get callbacks? Is my staff going to have to deal with this and as a patient, really not going to get what I feel is the most beneficial product for them. And then if it’s more of a buy and go situation, so for those infusible products where physicians take possession of the product and then bill the managed care company back for those products of reimbursement, you know, am I going to get reimbursed for this? It’s a huge cost to the physicians’ offices and I know some of you might be in that business where you actually have a buy and bill product. This is a huge risk for the physicians and this is one of the reasons why some of these oncology offices and other practices have been consolidating. They’re losing some money or they can’t float, have the cash flow to manage that. And it’s just not a viable business model for them anymore so they’re joining, you know, hospital or integrating delivery network and they want to know how this is going to impact their office financially and then ultimately when you look at things like compliance persistency and just the patient outcomes, can they afford this? How much are they going to pay out of pocket? How do I have the conversation with them? How is my staff going to have a conversation with them? What are some of the resources that are available to help support patients? It might not have the means to pay for some of these medications but definitely need them from a health perspective. So just a little quick diagnostic that, you know, you might want to ask of your own organization is, you know, do we have a common definition for access? And, you know, we find that you’ve got different silos and organizations, you got your market access strategy or managed care, different flavors but they’re basically in-charge of the pricing of market access. You’ve got your sales team, you’ve got your marketing teams and everybody is not always aligned in what market access is and they use different terms and we love terms in pharmaceuticals and acronyms. But we’re not all familiar with them. And do I understand the impact of that? That’s the organizations.

So different products and different therapeutic areas are impacted by healthcare reform and pricing in different ways. So you’ve got a retail model for your more primary care products where you’re looking at more of the copays and tiers and it’s about patient access, then you have more hospital based products where some of these are being bundled into payments and they have a DRG code. So you really need to understand how your portfolio is impacted and how the business models of the people that you use your portfolio are being impacted and then looking at that, so does your organization understand that? And then do we incorporate that into our strategic planning? And I think, you know, the answer to this is probably yes to most people but how much? And are we really thinking about the future? So it’s not just now in looking at what are our co-pay cards, you know, what’s our, you know, hub look like? What is our patient assistance program? And it’s more about how we’re engaging our customers. What resources are we providing to them? How can we help them and their patients? How do we get to the patients and help them? And then when you look at the tactical planning, how do we communicate all that to our representatives, our customer facing teams? And that’s again where the common language is really important, so that everybody is on the same page. And then ultimately, you know, how are we executing against that? And it’s not just selling the copay cards or the patient assistant program or hey, here, call this 800 number, we’ll take care of everything. Do we really understand how this impacts our customers’ business, so we can have a real conversation with them?

So what do our reps need to know? And what do they need to do? So we’ve identified kind of 6–I’m sorry, 7 behaviors or knowledge that will enhance your commercial success. So you need to be conversant with physicians about the access issues. Not just your programs and what you’re rolling out but what the issues are to that physician’s office or the offices. So again, looking at your therapeutic area, the type or in your primary care, are you in specialty? What are the different business models and can I have a conversation as representative with my customers? And understand what they’re going through, how their patients are impacted. How their practices impacted, and how that might impact the physician or the owner, so to speak, of that practice. Listen and identity issues. So again, a lot of times we go in there we’re just talking at physicians about our products and sharing all the wonderful things about what we can do for their patients but there’s a lot more going on. They don’t just treat patients with our products, and maybe treating other disease states as well. We need to listen and be able to identify issues and then handle them. You know, work with–engage the office staff, engage the physician to come up with some solutions or at least to find out more about what we can do and we can’t solve everything. There are a lot of things that customers would love us to do that we certainly know how to do but due to regulations we can’t do. But there are also a lot of things that we haven’t really done yet as a pharmaceutical companies that we could help out with. And part of that is just understanding and really defining the problems and understanding them. So the fourth is to connect physicians and patients to the resources. They don’t mean again, just dropping off a stack of copay cards or here are some patient education programs or here’s the 1-800 number to our customer service or hub. It’s how do we really show value, bring resources whether it’s people, things, information to our customers to help them better navigate and manage and get access and better outcomes for their patients and practice. And then number five is really to communicate. So as we’re gathering all this information as we’re engaging our customers, how do we feed this back into the organization? Do you have a mechanism in your organization where it’s actually captured and it goes somewhere or, you know, it’s just mentioned and it’s kind of a fleeting conversation with the manager or somebody else and it doesn’t go anywhere.

There is a lot of insights that the feel that are closest to the customer can provide to the organization beyond some of the market research that you and is there a way to communicate that back in? And do you encourage that? Is that your culture? Understand the access dynamics and the physicians and inform them. So things are changing around them, you know, the Sunshine Act is, you know, changing a lot of things and, you know, a lot of companies are looking at that right now and starting to communicate some things around the Sunshine Act for physicians but there’s a lot of other stuff changes. Health exchange is coming. You know, changes–Medicare, ACOs, how patients flow? Are we helping our customers understand? They’re very busy and they’re very focused generally on the clinical practice and their patients and they really don’t know. I’ve done a lot of research, talked to different physicians and, you know, from the time that the Accountable Care Act was passed to now and there’s a lot of still unanswered questions and we don’t have them either because it depends on how things are evolving. But there are a lot of things that have been answered. But there is not a lot of clarity amongst our customers as to what these things are. How they’re going to impact us? What do I need to do? What’s coming next? And again, I realized that we’re here to promote our products and, you know, ultimately make money for our company. So generally from a marketing perspective, when we get a little time with our customers, how do we just promote our product but you can build relationships and partnerships by talking about a lot of other things and customers are interested in information about their practices, their patients and it’s not just about your product, it’s about the solution that you can provide to them and how your product fits in to that they may be a little more willing to listen to you if it’s not like it’s a commercial coming in every time. So again, inform them of what’s going on around, they really would appreciate that. And then, you know, being flexible in adapting. So as you’re training your teams and healthcare dynamics are changing, how do we keep informed of those changes? How do we keep our team up-to-date, sharp, providing new skills or knowledge that are necessary to address those needs? You know, sometimes it’s new roles which is fine but then that requires more coordination. So every time we do something different, you know, we just need to be cognizant on how that impacts kind of the ecosystem that we’ve created on our internal team and then how that interacts with our customers externally. So for training perspective, you know, how do you make it stick and I was really glad to hear about the coaching aspect and pull through, it fit really well into my presentation because I think where we’ve been at as an industry with market access is with people do a workshop. So there is Medicare Part D, there are lots of workshops on and I’ve seen, you know, CDs from different workshops. So this kind of one and done events. Then we feel, no our team knows market access, we’ve trained them on it. Well, you know, a few things happen. One, you did an event, you know, you have attrition and promotions as your leaders rise up and new people come in and they don’t necessarily have that knowledge or skillset yet. And then also, we know how engaged and/or how much were they actually learning and retaining from that. So I mean, I’m sure most of you have been in any kind of a training function have seen these kinds of datasets over the years that, you know, we have this training event and you have this huge spike in knowledge and this is great. Our team knows what they’re doing. Everybody is talking about it. They’re excited, they’re going to go out in the field and execute but what happens is naturally post-event, we all are creatures of habit. So we go back to what we normally do and what we’ve been trained to do which is our commercials of our products and we know exactly where to go in the visual aid and things like that. How do we change that curve so that when we talk about other things and make it stick, we can take that curve and bring it up. So you’re always going to have a dip.

People go back but that’s where the coach–that’s where the manager, the field rides from other people marketing. That’s where your leaders in your teams, you know, other peer representatives that are leaders help to reinforce this and really make it stick and this is really critical and I think when you’re looking actually across the matrix teams, you know, since we all report up to different people in a market access, you know, medical sales, different functions. You’ve got nurse educators. You know, how do we keep it going for all of those teams so that we are all coordinating together.

So we’ve been using this implementation methodology we call A-Train at Campbell and it’s really to increase the stickiness if you will of training initiatives. So I think a lot of people do a great job at 1 and 2. So awareness, there is lots of communications that go out. There’s sometimes videos and campaigns and they brand it and it’s–here’s why we’re doing this, this is great. And then they do the training. It’s either live or virtual. Doesn’t really matter but that’s kind of where it ends. People take their binders way if they have them. They’ve got some kind of think house and a share drive somewhere or there’s a website but the key is to reinforce. So what’s the continuum look like? How do we continually reinforce what people have learned? Make sure they actually did retain it. How do we then again elevate it so train them some more and then assess them on it. So data points, critical. Often when we go and then talk to guys that we think that we know this. When you actually do an assessment then you actually know where you’re at and you’d be surprised and you probably have done different assessments in your organizations over the years that people don’t necessarily know these topics or have the skills that we think they do. There are some stars that do but when you’re looking at a whole team, where are we really at? And that really comes in through the inspection. So again, those first time managers. So what’s the pull through? What’s the continual reinforcement? What’s that accountability? If there is no accountability, people aren’t going to do it. People–a lot of that’s going to fall off. Unless they really see the value and it’s going to be a smaller percentage of your team that’s really focused on improving and getting better. Most of the other people might just be, I’m just doing my job, I’m checking the box, you know, and if I’m not getting any other guidance and no one’s pressuring me then I’m assuming I’m doing a good job. So, you know, ultimately very critical. Just some different modalities to do that and, you know, reinforce, so you have different kinds of communications and training, reinforcement, assessments and inspection which, you know, again coaching observations or performance management. So all critical ways to when you look at initiatives like market access, fluency, are critical to make sure there’s a stickiness and an uptake and an advancement. And that’s actually the critical thing is market access fluency is a capability. That’s not a skill or a knowledge. If you’re going to build it for your organization, it’s a capability. It’s going to take some investment and it’s going to take some time to get your team there. It’s really just kind of my key wrap up points and, you know, one is obviously the healthcare dynamics are evolving and is significantly impacting all of us. Meaning, the pharmaceutical manufacturers as well as our customers and all the different stakeholders, patient advocacy groups, the government, you know, the providers in different delivery sites of care, payers. We have an opportunity to build this capability in our organizations and train our people to actually engage customers, help them and patients ultimately get access to quality care that’s going to impact their lives and we have the solution for some of those things. That’s the great thing.

You know, the products that our companies make are what–are increasing the life expectancy for our, you know, population or enhancing the lives, quality of life and we just need to get them in the right hands and get access to them. And then basically, it’s a differentiator. Again, a lot of companies are just doing some training. They’ll have a vendor come in and this great workshop. It’s exciting. You do the workshop–what’s that continuum? How are you building the capability? How are you building it across the organization? So it’s breaking down some of the barriers where, you know, what is medical? What is access? And what are sales? And what are some of the other function? How do we get everybody on the same page versus, you know, different workshops in each of these verticals or departments? And we’re all kind of there but we’re not really speaking the same language or coordinating.

Nick: Thank you, Steve. My name is Nick Maryfield. I’m the Managing Director of–as you can tell by the accent, a UK business, and we’ve obviously lived with active benefit management for many years now. Probably 10 years in total. So it’s quite interesting to hear about medical policy protocols and guidelines. Is the inference that you don’t have many of those at the moment in the US, I assume that what I took from it, because for every disease and drug that we have…

Steve Daniel: Sure.

Nick: Everything is covered by that.

Steve Daniel: Yup.

Nick: So is that the case?

Steve Daniel: No. So it depends on the therapeutic area and usually cost is driving it a lot of times. But they are definitely a medical policies and Step Edits across different products. It’s–you’ll see it more when there is a crowded marketplace, so if you look at something like the anti-TNFs in rheumatoid arthritis. There is a lot of Step Edits and management around them because there is a lot of choices which gives payers the opportunity to leverage that and look at where they can get rebates and where they can look at clinical data to see what outcomes they get. Oncology is another area where, you know, as a marketplace gets more crowded, that’s where the leverage is. You know, there is, you know, categories with Medicare where you have to cover drugs. So you’ll be on formulary but, you know, and depending on your business and again, that goes back to what’s my therapeutic area? What’s the landscape and the competition look like? And you may not have any now but if you don’t, there may be more coming. So I think as the cost pressures continue and as payers are looking for an opportunity to control those costs and as you see maybe more products coming into your category as competition, you’ll see more of them. But there are certainly a number of those policies and step edits now but maybe not–it’s not quite as controlled as in the UK.

Nick: Okay. Just a kind of–well, thank you for clarifying that. I guess what we’ve witnessed is probably halving the number of sales reps. There is a consequence and a massive focused on market access particularly around the active benefit management and the industry has reinvented itself there by talking a lot more about patient pathways and understanding their healthcare cost. I don’t know if that’s something that happens to the US but it certainly worked for the UK market, putting that proposition in. But I was interested by that. Thank you.

Steve Daniel: So I mean, we’ve certainly seen a reduction in the number of sales reps and, you know, some of that’s also based off of the number of launches that have come and what products are viable to promote but, you know, certainly the arms race if you will of sales representatives in the ‘90s where it was all about reaching frequency and share a voice. That mile has really kind of died off. Physicians don’t have as much time. Information is very available and they’re looking for the value and I think again, that’s where, you know, it’s a combination of the clinical message as well as how can you help me with my practice and my patients to get access to this thing? That’s the thing I’m challenged with. You know I’d get in general how to treat these diseases. I know what products are available to me but this is evolving and its way–they didn’t teach me this in medical school. So, I think, you know, you’ll–I think there are some projections and you’ll see reduction in some of the number of medical sales reps but they’re shifting, too. So you’re seeing growth in MSLs or other kinds of reps. So a lot of companies are starting to have this access reimbursement representatives or even some reps that talk to clinical pathways or go into–they’re like an MSL that goes into payers to really show the value proposition and I think once–there’s a lot of question around some of the data. So the challenge in the US is we can really only promote on label so what’s in our package insert, but there is a section of the health code called FDAMA 114 that allows manufacturers to talk to people that make population decisions on access, generally payers, to talk about the pharmacoeconomic story and there’s not necessarily a lot of date out there from companies and aren’t just generating–they’re looking at it now and trying to generate that and they’re also looking at who are these people besides just the payers that could potentially get this data. So I think you’ll see your continued reduction to a degree unless there are a lot of launches coming up but you’re also seeing a shift in the type of rep that’s calling on a different type of customer, too.