IN-HOUSE DOCUMENTS. A large pharma company, KRKA, has been bribing doctors in Romania for over a decade and holds an “amortization” column in the Excel of bribe!

Ioana Vodă – Advance payment for an ORL course, she promised to prescribe at least 200 packs of Bilobil / month until the end of the year.

Line from the bribe Excel:

• The doctors would receive their commissions through “sponsorship agreements”. “Should they comply with their target, they would receive approximately 10% of the prescriptions value”, recalls one of the employees with a top position inside KRKA.
• Thanks to these “loyalty programs”magic sparkled for the company: sales were skyrocketing and the state was spending several millions euros per year on products like Bilobil, a ginkgo biloba based product, the reimbursement of which international experts had been warning for years it was not justified. 
• In return, patients were diagnosed with bogus “medical needs” so that doctors could comply with the “target” set by the company, as the number of prescriptions is referred to in the documents the paper starts to unveil to the public today.
• The outcome is that the company gets to rule on how the patient should be treated by the doctor.

KRKA Romania, with its hundreds of employees, is basically a marketing and lobby company, acting as an influencer regarding medical prescriptions. We, the ones from Romania, do not sell pharmaceutical products, as they are invoiced directly to distributors by the mother-company in Slovenia, where they are also manufactured.

An employee who has been working for over 15 years for KRKA:

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The first document presented in its entirety by Libertatea is called “Cerere sponsorizare medici excepții_ București_Q2_Total” (Sponsorship request doctors exceptions Bucharest Q2 Total) and it is an excel document from 2010. Doctors would receive money for prescribing a drug, the well known ginkgo biloba.

The employees of the company would get to write at the end of the Excel sheet „for this doctor we agreed to make the payment every two months” or they would ask the accounting department to include the doctor in the “loyalty program”, namely in the bribe circuit: “I have been monitoring this doctor since September last year and I have not paid her in any way, yet she has prescribed nothing but Bilobil (she has at the most 5 patients on tanakan suspension), so I do not want to lose her”.

One of the over 2,000 excel documents regarding bribe obtained by Libertatea from the inside of the pharma company:

The table shows the medical representatives, the salespersons in charge of doctors, then the names of the doctors, their specialty and the hospital or the clinic where they worked.  

The following column is called “Targetare” (Targeting), and it assorts the doctors to be approached, from A1 to C3, according to a matrix in which:

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• A1 signifies “doctors with high potential who prescribe from us” 
• A2 signifies “doctors with high potential who prescribe from us as well as from the competition”
• A3 signifies “doctors with high potential who prescribe from the competition” .

The same logic applies on the other columns, B signifying an average potential, while C – low potential.

„We would focus on A3, A2, B3 and B2, rather than on A1 and B1, the ones who were already prescribing from us and who were saturated”, explains a person with a top position within KRKA Romania.

KRKA is a Slovenian company active in over 30 countries, listed at the stock exchange in Ljubljana and with a turnover of 1.33 billion euros in 2018.

KRKA is one of the first foreign pharma companies to enter the market in Romania, with very significant sales in our country, having products well known for their high quality and large investments in marketing. 

“We would get the secret list from CNAS, where all the doctors are shown, with all the drugs they prescribed!”

The internal documents of the company show an internal mechanism “which they made us use and which would increase sales based on the connection with the doctors”, the employees told Libertatea. 

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After the columns with the doctors to be targeted by the “sponsorship”, the company Excel included a column named “Potențial” (Potential), where the pharma company states how much ginkgo biloba each doctor may prescribe. How would the company know such details? 

KRKA had someone at the Ministry of Health and at the National Health Insurance House and we would get, off the record of course, the secret list of the House where all the doctors are shown, with all the drugs they prescribed!

KRKA employee:

People from inside the company say that the lists from CNAS were delivered to them before 2010 and until 2013. Basically, when they would enter the doctors office, they knew everything that person had prescribed! If the subject of interest was, as in this excel, ginkgo biloba, they knew exactly how much bilobil or its equivalent from the competing companies each doctor had prescribed. 

“Of course we would not tell the doctors we had all their prescriptions, but you can imagine we had the upper hand. Through negotiation strategies we led them where we needed them. We promised them money and, one step at a time, we would sometimes grant them an advance payment and they promised they would prescribe a larger amount of packs of pharmaceuticals from us”, explains a “medical representative”, as the position holding the direct contact with doctors and pharmacies is called within the pharma industry.

In the following columns, the company estimated the potential value, basically all the money a doctor could generate by prescribing KRKA products. 

The column “Avans” (Advance payment) follows, where it is specified if the doctor received an advance payment and its value. 

The advance payment means money, money for “holiday trips to Palma de Mallorca”, “for ORL congress” or other incentive trips. 

The way in which the doctors would get their “commission” has been different from one stage of the company to another, during the last decade, as revealed by the employees:

1. “At the beginning we, the sales representatives, would get the money in our accounts and we would pay the doctors with cash”.
2. “Then there were the sponsorship agreements, with an ambiguous object, basically everybody knew it was a commission, amounting to about 10% of what they prescribed”.
3. “At a certain point, the trips to Slovenia emerged, with a trip to Venice included”.
4. “During last years and ongoing round tables are used, where they get paid as speakers”.

Our amounts were not that big. For a drug, the doctors would get a few hundred lei per quarter, the amount would rarely get up to 1,500 lei per doctor. It is true we had several drugs. Sure, the trips were worth more, about 1,000 euros. Anyway, compared to the innovative drugs companies, who would give away a key to a car or an apartment for the important doctors, our gifts were spare money and we would pay up front, like for prostitutes.

KRKA employee:

In the sponsorship Excel the column named “Perioada Amortizare” (Amortization period) follows, where the company estimates how much it will take to get return on “investment” from a doctor. 

“We would usually accept two or three quarters to get reimbursed for the money paid in advance”. How could you monitor that? “We would visit at the end of each month each doctor and we would count the prescriptions”, recall people inside KRKA. The company had over 200 employees.

The most dedicated doctors would get into the “loyalty programs”

The highest potential doctors get into the so-called “loyalty programs”. As the medical representatives have a sales target in order to get the bonuses at the end of the month or quarter, doctors commit in return to their own target: to assign a certain number of prescriptions with the drug manufactured by the company. 

That is how a big success of KRKA and one of the biggest black holes in the list of compensated pharmaceuticals were born. For over a decade, the Romanian state has reimbursed a naturist product, with a certain effectiveness, but proved not as relevant in the international studies as for the Ministry of Health to take money from their pocket that could have been spent on other vital drugs.

The stake worth 100 billion old lei 

The Romanian Government has been signaling for quite a while that something was fishy with the escalating prescriptions for certain pharmaceutical products.

Ever since 2002, Prime Minister Adrian Năstase warned that a plant based medicine, used mostly for Alzheimer treatment, was included among the top compensated drugs, generating yearly expenses of over 100 billion old lei. 

“Money are spent on drugs with disco names”, warned in 2002 the Romanian PM of that time, Adrian Năstase, aggravated by the fact that ginkgo biloba ranked among the top compensated pharmaceuticals, plant based pills used mainly but not exclusively for the Alzheimer patients. 

Ginkgo biloba (namely Bilobil, owned by KRKA or Tanakan, manufactured by Ipsen, by instance) would generate annually expenses of over 100 billion old lei.

“This can no longer go on”, said Năstase. But it did. For more than one decade. In 2006, Ginkgo Biloba appeared under the name of Bilobil in the ranking of the 20 compensated pharmaceuticals for which the state spent the most money. 

The golden drug

In an analysis from 2012, authored by Vlad Mixich for Hotnews, he noted that ginkgo biloba is one of the substances for which the experts from NICE (National Institute for Excellence in Health and Care) recommends beyond any doubt unlisting the product as its compensation “is not supported by undeniable data regarding positive effects”.  

It was only in 2015 that the Romanian authorities removed ginkgo biloba from the list of compensated pharmaceuticals, as until then the drug had continued to represent a golden mine of the pharma industry.

Nevertheless, the sponsorship Excel stands as only one example. The procedure was identical for all the tens of KRKA pharmaceuticals. 

These emails show hundreds of doctors from all over the country, divided on “districts”, as KRKA would divide Romania, three or four counties for a district. 

For instance, during the first financial quarter in 2010, 87 doctors in Bucharest were included in the “loyalty program” for Ginkgo biloba. Meaning they were reimbursed according to the amount of Bilobil prescribed to their patients. 

Out of the 87, according to the company report, 66 “achieve their target” 

The Excel data show an obvious connection between the number of prescriptions issued by the doctor and the received incentive. 

There is a note listed next to four family practice physicians (Moraru Tinca, Cocău Viorica, Doboş Mihaela, Botez Viorica), who were sponsored with amounts ranging from 1,570 to 1,873 lei: “holiday trip to Palma de Mallorca”. 

Ioana Vodă, an ear, nose and throat doctor who owns a renowned private clinic in Bucharest, is included in the same table from 2010 with the note: “Advance payment for ORL course, she promised to prescribe at least 200 packs of Bilobil per month until the end of the year”. 

The companys mistake 

Ioana Vodă is valuable to the company as she is regarded as key opinion leader, meaning she can also influence doctors from the same specialty as hers.

The advance payment is 3,790 and must be reimbursed by the end of the year through prescriptions. 

The KRKA business continued to thrive for a long time. Yet they made one mistake.  

“They mocked us, the money makers, the ones they sent to the doctors, reassuring us that everything is legal, that the company is audited,” recalls one of the employees Libertatea interviewed during the research period of the investigation. 

When laws got stricter, when the “sponsorships” needed to be accounted for and doctors wrote less prescriptions and the profit went down, the Slovenians and the Romanian board led by CEO Amelia Tătaru forgot about the good times and they begun the persecutions, the cost cutting and the firing

KRKA employee:

And people have begun letting everything out. 

In order to get an offical statement from the company management, the investigation team of the Libertatea newspaper went to Sovata, where starting from today, the annual KRKA meeting takes place. As she was expected to arrive in the afternoon, CEO Amelia Tătaru was late due to traffic jams. Here is how the dialogue between her and the team of journalists unfolded, at the moment of her arrival, close to midnight.

Amelia Tătaru: „Yes, I am the manager, I am the administrator, but I cannot make any statement”

-Good evening, Mrs. Tătaru. We would like to talk about the practices through which the company you are representing paid doctors to prescribe the KRKA pharmaceuticals.
-But I cannot discuss right now, as it is midnight, lets talk about it in the morning. 

-We are very sorry, it is an important discussion, we have thousands of Excel documents from the inside of KRKA showing how the prescriptions were done in exchange for money.
-But you are aware that every company holds a communication protocol. You will have to comply with the protocol of communication with the press.  

-That is true, but we have evidence regarding sponsorship agreements with an ambiguous object.
-OK, so you received the documents and I have no other way but to comply with the KRKA protocol, this is my duty as a manager. 

-But you are not only a manager, you are also a legal representative, an administrator, and all these deeds were undergone under your mandate.
-Yes, I play all the parts, both the one of manager and the one of administrator, but I cannot make any statement, we have a very strict protocol. So, if you have a list of questions you may address them to me..

-besides the documents, we spoke to people from the company and there are rather serious accusations, for example that you got an illegal hold of the lists with doctors and the pharmaceuticals prescribed by them from the Public Health Insurance House. Have you heard anything about this possession? Dont you want to talk at all about this??
-No, I cant. 

-You cannot or you do not want to?
-I cannot go against the companys protocol. We hardly make any statements to the press, during 10 years KRKA held 2 interviews, I think.

-We will go public anyway, but it was our duty to come all the way here, to Sovata, where you hold your annual meeting, to give you the opportunity to clarify things.
-Yes, of course you do whatever you want, I cannot give you any confirmation or any… I cannot talk to the press, I lack this ability.  

-And who should talk to the press? 
-For the press you should provide me with a list of questions, I send it to the PR department in Slovenia and they will answer you. 

Another Excel document that shows the way the bribe was monitored: 

Translated by Karina Han

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