The Physician-Pharma Relationship. PharmedOut.org 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 PharmedOut.org 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 • 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 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 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 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 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
“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
Detailing • 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
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
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
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
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.
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
“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)
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
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
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.
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
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
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
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
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? • 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