The Physician-Pharma Relationship
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The Physician-Pharma Relationship. Georgetown University Medical Center January 2008. The Physician-Pharma Relationship. Is very old and very close But are the goals of pharmaceutical companies and medicine the same? . Promotion includes. Detailing

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The Physician-Pharma Relationship

Georgetown University Medical Center

January 2008

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The Physician-Pharma Relationship

  • Is very old and very close

  • But are the goals of pharmaceutical companies and medicine the same?

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Promotion includes

  • Detailing

  • Meetings and events (dinner meetings, CME, rounds, symposia)

  • Publications (symposia, monographs, supplements, throwaways)

  • Advertising and reprints

  • Direct mail, e-detailing

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Top 10 products by US Sales, 2006 (IMS 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

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The 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

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Promoting 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

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New drugs are not necessarily 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

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

  • 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. Abstract

Lurie N et al. J Gen Int Med 1990;5(3):240-243. Abstract

Wazana A. JAMA 2000 Jan 19;283(3):373-80. Abstract

**Sigworth SK et al. JAMA. 2001 Sept 5;286(9):1024-5. Abstract

McKinney WP et al. JAMA 1990 Oct 3;264(13):1693-7. Abstract

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  • 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. Abstract

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The AMA Physician Masterfile

  • 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

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AMA’s Prescription Data 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

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AMA’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. Full text

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What 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.

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Ex-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

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“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)

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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

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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

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The real purpose of samples

  • 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

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Samples are a marketing tool

“…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.

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Meetings 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

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Pharma 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

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Advertising in medical journals

  • More than 95% of JAMA ads are for Rx drugs

  • 5 of 6 physician organizations raised at least10% of annual revenue from ads in affiliated medical journals

  • Pharma companies also purchase “sponsored” subscriptions

  • And are the largest purchaser of reprints

Fugh-Berman A, Alladin K, Chow J. PLoS Med. 2006;3(6):e130. Full text

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Correct message retention by media mix

  • No promotion 14%

  • Detail only 21%

  • Detail and print [ads] 36%

  • Detail and sales aid 33%

  • Detail and print and sales aid 44%

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

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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.

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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

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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 or 202-687-1191.

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