The Physician-Pharma Relationship

PharmedOut.orgGeorgetown University Medical

CenterJanuary 2008

The Physician-Pharma Relationship

Is very old and very close But are the goals of pharmaceutical companies

and medicine the same?

Promotion includesPromotion includes

Detailing Meetings and events (dinner

meetings, CME, rounds, symposia) Publications (symposia, monographs,

supplements, throwaways) Advertising and reprints Direct mail, e-detailing

Top 10 products by US Sales, 2006 (IMS Top 10 products by US Sales, 2006 (IMS Health)Health)

Lipitor $8.6 billion Nexium $5.1 billion Advair diskus $3.9 billion Aranesp $3.9 billion Prevacid $3.5 billion Epogen $3.2 billion Zocor $3.1 billion Enbrel $3.0 billion Seroquel $3.0 billion Singulair $3.0 billion

IMS national sales perspectives. IMS Health. 2007 Mar. Table

The costs of promotionThe costs of promotion

In 2004, total promotion cost for Rx drugs was almost $30 billion

About $7 billion spent on detailing NIH budget FY 2008 is $29 billion* FDA budget FY 2008 is $2 billion**

West D. Changing lanes. Pharm Exec. 2005 May;25(5):154-162. Full text *NIH summary of the FY 2008 president’s budget, 2007 Feb 5. Summary**Summary of FDA’s FY 2008 budget. Summary

Promoting the profitablePromoting the profitable

There are more than 10,000 drugs in the US pharmaceutical market

More than half of promotional expenditures are concentrated on the top-selling 50 drugs*

*Ma J et al. Clin Ther 2003;25(5):1503-17. Abstract

New drugs are not New drugs are not necessarily better drugsnecessarily better drugs

Most new drugs are me-too drugs, or combinations of old drugs

In general, generic drugs are safer than branded drugs simply because more information is available about them

Studies consistently show that promotion increases prescribing*

Studies consistently show that physicians do not believe that promotion affects prescribing**

*Chren MM and Landefeld CSl. JAMA 1994 Mar 2;271(9):684-9. *Chren MM and Landefeld CSl. JAMA 1994 Mar 2;271(9):684-9. AbstractAbstract Lurie N et al. J Gen Int Med 1990;5(3):240-243. Lurie N et al. J Gen Int Med 1990;5(3):240-243. AbstractAbstract Wazana A. JAMA 2000 Jan 19;283(3):373-80. Wazana A. JAMA 2000 Jan 19;283(3):373-80. AbstractAbstract**Sigworth SK et al. JAMA. 2001 Sept 5;286(9):1024-5. **Sigworth SK et al. JAMA. 2001 Sept 5;286(9):1024-5. AbstractAbstract McKinney WP et al. JAMA 1990 Oct 3;264(13):1693-7. McKinney WP et al. JAMA 1990 Oct 3;264(13):1693-7. AbstractAbstract

“Doctors are too smart to be bought by a slice of pizza“

DetailingDetailing

In 2005, there were about 600,000 doctors and about 100,000 drug reps in the US

Actual ratio about 1 rep per 2.5 targeted docs*

Targeted docs are high-prescribers, or docs who control market share*Goldberg M et. al. Pharm Exec. 2004 Jan 1;24:40-5. *Goldberg M et. al. Pharm Exec. 2004 Jan 1;24:40-5. AbstractAbstract

The AMA Physician The AMA Physician MasterfileMasterfile

Contains demographic data that the AMA has sold to industry continuously since the 1940s*

In 2005, licensing Masterfile information and other database product sales provided about 16% ($44 million) of the AMA’s revenue**

*Greene JA. Ann Int Med. 2007 May 15;146:742-8. Full text

**Steinbrook R. NEJM. 2006 Jun 29;354(26):2745-7. Abstract

AMA’s Prescription Data AMA’s Prescription Data Restriction Plan (PDRP)Restriction Plan (PDRP)

Few physicians know about it < 1% of doctors have signed up "Just giving them an option [to opt-out]

alleviates their concerns," explained the AMA’s senior VP of publishing and business services to Pharmaceutical Executive Herskovits B. Pharm Exec Direct. 2006 Jul 19. Full

text

AMA’s Opt-out planAMA’s Opt-out plan

“The restrictions do not apply to (a) deciles at the market or therapeutic

class level (b) segmented data that are not likely to

reveal the actual or estimated activity of an individual physician, or

(c) data on products ordered by physicians from pharmaceutical companies.”

Musacchio RA and Hunkler RJ. Pharm Exec 2006 May 1. Musacchio RA and Hunkler RJ. Pharm Exec 2006 May 1. FullFull texttext

What drug reps costWhat drug reps cost

Average annual income for a drug rep is $81,700*

Per rep per annum, pharma spends $150,000 ( primary care) $330,000 (specialty) Sales force costs are 5% - 8% of

revenue**

*Goldberg M and Davenport B. Pharm Exec. 2005 Jan 1;25(1): 70. Full text

**Niles S. Med Ad News. 2005 May;24(5):1-4.

Ex-reps speak outEx-reps speak out

During training, I was told, when you’re out to dinner with a doctor, “The physician is eating with a friend. You are eating with a client”. Shahram Ahari*

“The essence of pharmaceutical gifting…is ‘bribes that aren’t considered bribes.”

Michael Oldani You are absolutely buying love.

James Reidy*Fugh-Berman A and Ahari S. PLoS Med. 2007 Apr 24;4(4):e150. Full text Elliott C. Atlantic Monthly. 2006 Apr;297(3):82-93. Full text

“I don’t listen to the reps” <1 minute of a sales

reps interaction with a doctor results in a 16% prescribing change

3 minutes with a doctor results in a 52% prescribing change

Prounis C. Best foot forward. Communique, vol 7. Full text (also

downloadable pdf)

“I only see reps for the samples”

Why docs like samples

Start treatment immediately Test tolerance to a new drug Reduce the total cost of a Rx Provide free medication to those

who can’t afford it

Why drug companies like samples

Increases “new starts” on a new drug

Encourages switches from other drugs

Patients usually stay on the sampled drug

Increases prescriptions of the most expensive, most promoted drugs

Gain access to physicians Habituate physicians to

prescribing targeted drugs Increase goodwill by enabling

doctors to give gifts to patients Serve as unacknowledged gifts to

physicians and staff

The real purpose of samples

Samples are a marketing Samples are a marketing tooltool “…the manufacturer needs to

figure out the right amount of samples the rep has to drop off in order to maximize the number of paid prescriptions written.”

Tsang J and Rudychev I. Medical Marketing & Media. 2006 Feb;41(2):52-8.

Meetings and eventsMeetings and events

“Nearly 30 percent of physicians who attend association meetings refuse to see reps in their office…a no-see strategy is critical for companies to overcome”Rehal D. Successful Product Manager’s Handbook. Pharm Exec. 2007 Mar 1;7:8-15. Full text

Pharma controls CMEPharma controls CME

In 2006, over $2.3 billion dollars was spent on CME More than half of this came from

pharmaceutical manufacturers Medical Education and Communication

Companies (MECs) 76% of income is from firms that manufacture

FDA-regulated products Medical schools

62% of CME income to medical schools comes from pharma (ACCME) ACCME Annual Report Data 2006, Table 7. 2007 Jul 6. Report

Advertising in medical Advertising in medical journalsjournals

More than 95% of JAMA ads are for Rx drugs

5 of 6 physician organizations raised at least 10% of annual revenue from ads in affiliated medical journals

Pharma companies also purchase “sponsored” subscriptions

And are the largest purchaser of reprintsFugh-Berman A, Alladin K, Chow J. PLoS Med. 2006;3(6):e130. Full text

“I Never Read the Ads”

No promotion 14% Detail only 21% Detail and print [ads] 36% Detail and sales aid 33% Detail and print and sales aid

44%

Correct message retention by media mix

Paul CM. Medical Marketing & Media. 2006 Dec;41(12):60-2. Full text

What about R&D costs?What about R&D costs?

Pharma spends 2-3 times as much on marketing as it does on research

Edwards J. Brandweek. 2005 Feb 7; ;46(6):24-6.

Is promotion worth it?Is promotion worth it?

In 2006, the ten best-selling global pharma brands made $53.5 billion*

In 2001, the average return on investment per dollar spent on promotion was $12.70**

*Robins R. Successful Product Manager’s Handbook. Pharm Exec 2007 Mar 1;7:38-41.

**Niles S. Med Ad News 2004 Mar;23(3):1

Educational materials, news, resources, film clips, slideshows, articles, book list

Links to reliable, free drug information Links to 300 credits of pharma-free

CME Soon, our own CME modules on

pharmaceutical promotion

Funded by the Attorney General Consumer and Prescriber Education grant program, created as part of a 2004 settlement between Warner-Lambert, a division of Pfizer, Inc., and the Attorneys General of 50 States and D.C., to settle allegations that Warner-Lambert conducted an unlawful marketing campaign for the drug Neurontin® (gabapentin). Contact us at http://www.pharmedout.org or 202-687-1191.

Thank you

References