Pharmaceutical Marketing to Physicians

Pharmaceutical Marketing to PhysiciansIrina Bubnova, Erica Navarro, Camryn Fisher, Stephanie Knippa, Jacqueline Tilden

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Origins of Drug MarketingEarly twentieth centuryNo distinction between prescription and OTC drugsConsumers could buy any desired patented medication at the local pharmacySelf-treatment was prevalentDrug companies heavily advertised in newspapersEffects of medications were often exaggerated and ingredients and risks omitted from the advertisement

In the early twentieth century there was no real distinction between prescription and over-the-counter drugs. With a few exceptions, consumers were able to buy any medication they desired without a prescription from the doctor (Donohue, 2006). Self-treatment was prevalent, prompting the drug companies to heavily advertise in newspapers. There were no regulations on how truthful an advertisement had to be, which resulted in the majority of ads being grossly exaggerated. Also, it was very rare for the side effects, risks, and active ingredients to be published (Donohue, 2006). Consumers had no protection from the marketing schemes of the drug companies.

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Shift Toward Physician Based MarketingAmerican Medical Association (AMA)Disapproved of self-treatment and felt it was a threat to the medical professionFounded a council in 1905 to set standards for drugsEncouraged medical journals to stop advertising ineffective patented medications and for physicians to stop prescribing themApproved of drug companies marketing to physicians and considered this an ethical practice

The American Medical Association (AMA) high disapproved of self-treatment and felt it was a treat to the medical profession (Donohue, 2006). If a consumer could just buy any medication he/she wanted then the physician was no longer necessary. In 1905, the AMA founded a special council in order to set standards for drugs and to evaluate their effectiveness. The goal was to encourage patients to stop using ineffective patent medicines and to start using effective physician prescribed medications. At the same time, the AMA asked medical journals to stop advertising ineffective drugs and urged physicians to stop prescribing them. As a way to combat the direct-to-consumer newspaper advertisements, the AMA instead encouraged drug companies to advertise directly to physicians. The AMA considered this an ethical practice (Donohue, 2006). This created an incentive for the pharmaceutical companies and slowly they began to shift their focus to physicians instead of consumers.

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Marketing TacticsDetailingSponsoring continuing medical education (CME)Advertising drugs in medical journalsFunding medical specialty societiesHiring medical opinion leadersPaying physicians for participating in post-market research

One of the most basic marketing practices the pharmaceutical company engages in is called detailing. This is where a drug company sales representative personally contacts physicians, brings them meals, and gives them small gifts such as pens, mugs, and notepads. All these gifts obviously have the drug company logo or the drug name inscribed on them. Pharmaceutical companies also often sponsor continuing medical education (CME). Physicians needs CME hours to maintain their licensures, which creates the perfect opportunity for drug companies to slip in material about their drugs (Jost, 2010). This practice has received some backlash lately so drug companies have instead begun sponsoring CME indirectly though commercial providers (Jost, 2010). Other tactics include: advertising drugs in medical journals where physicians can read about them, funding medical specialty societies, hiring medical opinion leaders to consult and/or speak for the drug company, and paying physicians for participating in post-market research (Jost, 2010).

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Marketing Expenditures2012 pharmaceutical marketing expenditure breakdown:$15 billion detailing$5.7 billion free samples$2.1 billion CME

In 2012, pharmaceutical companies in the US spent $15 billion on detailing, $5.7 billion on free samples, and $2.1 billion on educational events for physicians (Drugwatch, 2015). The pharmaceutical industry often cites research and development as the reason for the escalating drug prices, but statistics show that for most companies, the money spent on marketing equals or even surpasses what was spent on R&D (Drugwatch, 2015).

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Current RegulationsThe pharmaceutical industry is mostly self-regulated by various medical organizations such as AMA or PhRMA2009 PhRMA regulations for marketing practices:Non-educations gifts such as pens and mugs are prohibitedModest meals are allowedDrugs samples are allowedOther educational gifts valued at less than $100 are allowedDue to many loopholes in the voluntary guidelines, the pharmaceutical industry remains mostly unregulated

Regulations for marketing practices are for the most part voluntary and imposed by various medical organizations such as the AMA or the Pharmaceutical Research and Manufacturers of America (PhRMA). The latest PhRMA guidelines which were published in 2009: prohibit non-educational gifts such as pens and mugs, allow modest meals, allow drug samples, allow other educational gifts valued at less than $100 (Grande, 2010). Because these guidelines are voluntary and have so many loopholes, the marketing practices of the pharmaceutical industry remain mostly unregulated.6

Ethical Considerations and InfluenceMany physicians deny that promotional items from these companies influence their professional objectivityEvidence suggests that physicians are just as susceptible to target marketing as any other person

Pharmaceutical companies have proven to be very effective in influencing the prescribing habits and preferences of doctors. Physicians and other health care professionals often develop relationships with pharmaceutical representatives, which can affect their care practices and result in a conflict of interest. Even simple notepads and other small gifts featuring the brand of pharmaceuticals help to establish brand recognition (Katz, Caplan, & Merz, 2010, p. 11). Although seemingly harmless, a simple conversation, lunch, and exhibition of branding can influence even the most level-headed of physicians, ensuring buy in and sales for the pharmaceutical company. While many physicians deny that promotional items from these companies influence their professional objectivity, there is much evidence that physicians are just as susceptible to target marketing as any other person (Katz, et al. 2010, p. 12).

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Personal AutonomyPersonal autonomy allows for an individual to make decisions based on their ethical valuesPersonal autonomy is compromised when another party influences anothers beliefs about a product or service

Personal autonomy allows for an individual to make decisions based on their ethical values, which have been formulated by their own experiences and beliefs. Physicians, while associated with healthcare organizations, do have the autonomy to treat patients and choose products based on their own research, intelligence, and experience. However, according to Pluog and Holm (2013) a physicians personal autonomy is compromised when another party influences their beliefs about a product (Pluog & Holm, 2013, p. 26). When this influence is in regards to the safety and efficacy of pharmaceutical products it can impact the physicians, organizations, and patients involved.

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Healthcare OrganizationsMultiple ethical theories must be considered when developing policies to discourage physicians from interacting with pharmaceutical professionals.Further regulating these relationships may cause and adverse reaction, prompting physicians to seek out this influence to protect their integrity and demonstrate their ability remain objective.Because people tend to desire freedoms more when faced with the threat of losing them, restrictions would not only irritate physicians who (over)value drug company gifts, but physicians who have historically been indifferent to them might find themselves valuing the gifts more

Healthcare organizations and administrators must be aware of how these practices can interfere with their patients and the ethical issues that arise from it. The ethical considerations behind this trend are complex, as simply adhering to one ethical perspective as an organization can lead to further conflict. Organizations must consider a multitude of ethical theories in order to properly establish a grounding for their physicians and organization as a whole. Healthcare organizations can help to discourage conflict of interest by developing a policy that eliminates gift acceptance within the organization. While this method could be construed as unethical and a threat to physician autonomy, the objective would be to prevent harm from the majority.

Psychology research does suggest that placing restrictions on a physicians professional behavior will most likely be viewed as an attack on their personal and professional freedom and integrity, leading them to seek out the influence instead of avoid it (Katz, et al. 2010, p. 15). Katz et al. (2010) explains that:

Because people tend to desire freedoms more when faced with the threat of losing them, restrictions would not only irritate physicians who (over)value drug company gifts, but physicians who have historically been indifferent to them might find themselves valuing the gifts more (Katz, et al. 2010, p. 15).

Threatening an individuals personal autonomy can be interpreted as an attack on the individuals morals and values. Physicians are entrusted with caring for their patients and adhering to the ethical principals in place. While not all pharmaceutical influences are bad, physicians must also carefully examine the possibility that these influences can affect their own autonomy as well. Health care organizations must find a way to ensure physicians feel a sense of integrity and personal autonomy when practicing medicine, while protecting the rights of the patients. While the influences of pharmaceutical gifts and messages are not always apparent, healthcare organizations must ensure their physicians understand they are not obliged to reciprocate these gifts by prescribing certain drugs or products. They have an ethical and moral responsibility to perform the necessary research needed to ensure patients are being prescribed the safest and most effective products and medicines.

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Pros of Pharmaceutical MarketingImproving health outcomesCreating products that save millions of livesCost savingsThrough innovation, development and competitionEconomic benefitsDevelopment of drugs in other countries benefiting the United States

Arguments in favor of pharmaceutical marketing include: improving health outcomes due to the use of newly developed and distributed products, some cost savings because of innovation, and the economic benefits of finding out about drugs that were developed outside the US.

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Pros ContinuedImproving Health OutcomesPhysician education Lifesaving treatments for failed therapies Treatment of infections & chronic diseaseInfluenzaSTDsCardiovascular diseaseDiabetesHepatitisCancer and many more

One of the greatest pros of pharmaceutical advertising to physicians includes providing physicians with up to date information on new drugs that have hit the market. Having the latest treatment options may provide physicians with potentially lifesaving treatments for patients who have failed other drug therapies. According to the U.S. Bureau of Labor Statistics, the pharmaceutical industry develops and produces products that help treat a variety of diseases, saving millions of lives and helping people suffering from diseases and illnesses to recover and lead more productive lives (Christ, n.d, para. 3). Treating every type of condition imaginable, such as influenza, sexually transmitted diseases, cardiovascular disease, diabetes, hepatitis, Parkinsons disease and cancer, to name a few.

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Pros ContinuedCost SavingsPharmaceutical company competition Drugs today are cheaper and more accessible than ever before due to increased competition in the marketplace (Boldrin & Levine, n.d, p. 15)Generic drugs availableIncreased competition in the marketplace increases the amount of available generic drugs to patients.Economic developmentEconomic development in countries like India and China are driving down global prices for pharmaceutical products

Pros for Cost Savings: Increasing competition among pharmaceutical companies are driving down drug prices. This increasing competition positively affects the amount of available generic drugs to patients. Economic development in countries like India and China are driving down global prices for pharmaceutical products.

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ConsBiased prescription practicesMDs are persuaded to use certain brands of drugsMost MDs deny being personally influenced, but agree that other MDs areSome MDs have contracts with drug companiesSome are unintentionally biased

While pharmaceutical companies play a vital role in healthcare today, physician directed advertisements have become a hot topic. Recently, the medical industry has begun questioning the ethics of advertising directly to physicians. And, while there are benefits to physician-directed ads, there are also disadvantages. Biased prescription practices and incorrect or misleading information are just a few of the drawbacks.

Although advertising to physicians may help educate them about new medications, it also persuades them to use certain medications in lieu of cheaper and/or (possibly) more effective ones. As mentioned, it is important for physicians to stay up-to-date with current medical practices and medications. However, it is also important that physicians remain neutral while prescribing these medications to their patients. Unfortunately, because pharmaceutical companies have the ability to provide physicians with gifts, incentives, and promotional items, it becomes hard to remain unbiased. When asked, most doctors would say they are not influenced by the gifts they receive; however, recent studies prove that to be untrue (Morreim, 2001.).

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Cons ContinuedDrug SamplesPatients receive free of chargeUsed to test effectiveness of drugs/help low income patientsCurb patients cost initially, but costs more in the long runAccompanied by skewed and misleading informationPersuade MDs not to look for better options

Along with these gifts, physicians are also provided with free drug samples. Unfortunately, while the samples are free allowing the physician to test the effectiveness of the drug and saving the patient money in the beginning the physician generally chooses to prescribe that drug instead of looking into other options. Ultimately, this almost always costs the patient more money than it would if they were prescribed a different drug. On top of that, there may be a better, more effective drug (or nondrug treatment) available. But, because the physician has been influenced to use certain medications, the patient may not be receiving the best treatment for their ailment.

Apart from being unknowingly biased about certain medications, physicians are also subject to doling out incorrect information to their patients. Unfortunately, the educational material provided by the pharmaceutical companies is greatly skewed in their favor. Very often these materials leave out pertinent information and suppress unfavorable research results. This leaves the physician believing that they are well educated about certain medications, when in reality, they have been misled.

In addition, physicians believe that they are immune to the influences of marketing; however, according to Physicians Under the Influence: Social Psychology and Industry Marketing Strategies, Studies suggest that although physicians believe they can extract objective information from sales pitches, they routinely fail to distinguish between correct and incorrect information provided by sales representatives. (Sah & Fugh-Berman, 2013). Unfortunately, the ultimate price of this misinformation is paid for by the patient.

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A Bad Investment: Doctors and Big Pharma

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Solution 1Refocus on patient needs by:Building more connections with patient organizationsProviding education material vs. marketing materialProviding cost-effective access to medicationsAltering marketing practices by changing pay structure and employee incentives

The first solution is to refocus on patient needs. Patients need to know that their physicians as well as the pharmaceutical companies have their best interests at heart. Drug companies can improve their image by connecting with patient organizations and by providing more educational material instead of strictly marketing material. It is also important to provide cost-effective access to drugs for all patients and providing adherence programs for the drugs they provide. Refocusing on the patient also means the companys board needs to be harder on their employees bad ethical behavior. Companies should reform its marketing practices by altering its pay structure and incentives to drug detailing representatives, severing the connection between sales and their compensation and eliminating compensation to doctors for promoting its products. With the help social media, drug companies can implement this and other programs and engage in an effective dialog with patients (Kessel, 2014).

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Solution 2Prohibiting all gifts and perksAll gifts can be a for of briberyPhysicians often feel the pressure to reciprocateProhibit Pharmaceutical companies from offering or sponsoring CME courses

The second solution that could be implemented is prohibiting all gifts no matter what the monetary value. Gifts are essentially a form of bribery and passing legislature that prohibits this kind of practice would effectively stop physicians from being negatively influenced. Once a gift is given, there is often an unsaid obligation for reciprocation. Physicians show this by selecting certain medications and by partnering with certain pharmaceutical companies for all of their prescriptions.

Restricting the pharmaceutical companies from providing and offering CME courses for physicians would greatly help in the conflict of interest of partnership between the physician and the pharmaceutical companies. Although it is important that all physicians stay up to date on their educational hours, it should be the responsibility of the physician to seek out and pay for the courses.

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Solution 3Elimination of unethical and questions payment to physiciansPaying physicians for post-market research should stopIt is a conflict of interest for a physician to be employed by a drug company and expected to also buy their product

The third solution should be to eliminate any unethical or questionable payments to physicians. This can be done by stopping physicians from getting paid for post-marketing research. Drug companies hope to evaluate side effects and drug effectiveness, but in reality doctors tend to collect little useful data (Jost, 2010). Eliminating this type of practice can reduce the pressure physicians feel to purchase certain medications from a pharmaceutical company that is also employing them.

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ReferencesBoldrin, & Levine (n.d). The Pharmaceutical Industry. Against Intellectual Monopoly, 1-36. Retrieved from http://levine.sscnet.ucla.edu/papers/imbookfinal09.pdfChrist, S. (n.d). The Benefits of the Pharmaceutical Industry. Retrieved from http://levine.sscnet.ucla.edu/papers/imbookfinal09.pdfDonohue, J. (2006). A history of drug advertising: The evolving roles of consumers and consumer protection. The Milbank Quarterly, 84(4), 659-699. doi: 10.1111/j.1468-0009.2006.00464.xDrugwatch. (2015). Pharmaceutical marketing. Retrieved from https://www.drugwatch.com/manufacturer/marketing/

References ContinuedGrande, D. (2010). Limiting the influence of pharmaceutical industry gifts on physicians: Self regulation or government intervention? Journal of General Internal Medicine, 25(1), 79-83. doi: 10.1007/s11606-009-1016-7Jost, T. S. (2010). Oversight of marketing relationships between physicians and the drug and device industry: A comparative study. American Journal of Laws & Medicine, 36, 326-342. doi: 10.1007/978-3-642-00612-8_15Katz, D., Caplan, A. L., & Merz, J. F. (2010). All Gifts Large and Small: Toward an Understanding of the Ethics of Pharmaceutical Industry Gift-Giving. American Journal Of Bioethics, 10(10), 11-17. doi:10.1080/15265161.2010.519226

References continuedMorreim, H. E. (2001) Prescribing Under the Influence. Markkula Centers for Applied Ethics. Retrieved from https://www.scu.edu/ethics/focus-areas/bioethics/resources/prescribing-under-the-influence/Ploug, T., & Holm, S. (2013). Pharmaceutical NudgingReinterpreting the Ethics of Evaluative Conditioning. American Journal Of Bioethics, 13(5), 25-27.Sah, S., & Fugh-Berman, A. (2013). Physicians under the Influence: Social Psychology and Industry Marketing Strategies. Journal Of Law, Medicine & Ethics, 41(3), 665-672.