Persuading Prescribers

Presentation Transcript

Adriane Fugh-Berman MD

Georgetown University

Wilson Lectureship, Albuquerque

September 29, 2006

PharmedOut.org (c) A. Fugh-Berman

Drugs are important..

But so is rational use
The most-promoted drugs are not necessarily the best
Drugs are not benign

Drug CostsAccording to the CDC…

Between 1997 and 2002 prescription drug expenses increased from 14% to 23% of total health care expenses
In 2002, average expenses for Rx drugs were about $1,100 per person (75% higher than 1997)
In 2002, average out-of-pocket expenses for prescription drugs were about 50% higher than in 1997 (http://www.cdc.gov/nchs/data)

Drug CostsAccording to the GAO…

Drug costs constitute 10.7% of health care expenditures
In 2004, spending for prescription drugs was $188.5 billion, almost five times what was spent in 1990

GAO. Price Trends for Frequently Used Brand and Generic Drugs from 2000 through 2004. http://www.gao.gov/new.items/d05779.pdf

Kaiser Family Foundation

From 1994 to 2004, in the U.S.

Population grew 12%
Number of Rx purchased increased 68%
Retail Rx prices increased 8.3% annually
Inflation rate was 2.5% annually

http://www.kaiseredu.org/topics_im.asp?id=352&parentID=68&imID=1

Use of drugs by elders

More than 90% of persons ≥65 years old used a least one medication per week
More than 40% used at least 5 medications per week
12% used at least 10 medications per week

Kaufman DW. JAMA 2002;287:337

“As use of medications grew between 1980 and 2000, the number of days Americans spent in the hospital fell by 56 percent, representing 206 million days of unneeded hospital care in 2000 alone. Although this study does not show that drugs caused the number of hospitalizations to fall, it is likely that they played a role.”

PhRMA. Pharmaceutical Industry profile, 2006. http://www.phrma.org/files/2006%20Industry%20Profile.pdf

PHRMA’s view…

ADR Frequency by Drug Use

Frequency (%)

0-5

6-10

11-15

16-20

Number of Medications

May FE. Clin Pharmacol Ther 1977;22:322-8.

Slide courtesy of Karim Calis, NIH

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

Promotion includes

Detailing
Advertising in journals
Meetings and events
E-detailing
Direct Mail
Publications
DTC advertising

Docs vs. Reality

Studies consistently show that promotion consistently increases prescribing of targeted drugs*
Studies consistently show that physicians do not believe that promotion affects prescribing**

*Chren MM et al. JAMA 1994 Mar 2;271(9):684-9; Lurie N et al. J Gen Int Med 1990;5:240-243; Wazana A. JAMA 2000 Jan 19;283(3):373-80.

**Sigworth SK et al. JAMA. 2001;286(9):1024-5.McKinney WP et al. JAMA 1990;264(13):1693-7.

The costs of promotion

In 2000, total promotion cost for Rx drugs was almost 16 billion dollars
About $5 billion spent on detailing
Sales force expenditures average $875 million per company

Detailing: In a poll of 2608 practicing physicians …

9% said information provided by reps was “very accurate”
72% said information was “somewhat accurate”
14% said that it was “not very” or “not at all” accurate”
15% found information provided by reps “very useful”
59% found it “somewhat useful”

Kaiser Family Foundation National Survey of Physicians, May 2002. http://www.kff.org

Detailing: A rep’s view

An official job description for a pharmaceutical sales rep would read: Provide health-care professionals with product information, answer their questions on the use of products, and deliver product samples. An unofficial, and more accurate, description would have been: Change the prescribing habits of physicians.

Reidy J. Hard Sell: the evolution of a Viagra salesman. Andrews McMeel

Publishing, Kansas City: 2005

What drug reps cost

Between 1995 and 2005, the number of drug reps in the US increased from 38,000 to 100,000
Pharmaceutical companies spend $150,000 annually per primary care rep and $330,000 per specialty rep*
Average annual income for a drug rep is $81,700 ($62,400 plus $19,300 bonuses)**

*Med Ad News 2004;23(3):1; ** Pharm Exec 2005 (January)

Meetings and events

Dinner meetings
Rounds
Symposia
CME

Meetings:Pharma controls CME

In 2004, more than half of the $2 billion dollars spent on CME came from pharmaceutical manufacturers
Medical Education and Communication Companies (MECs) launder money for pharma

75% of their income is from firms that manufacture FDA-regulated products

Medical schools are just as bad

Pharma provides almost two thirds (63.8%) of CME income to medical schools (ACCME)

Some universities court Pharma

“CCOE and UMDNJ faculty can advise, assist and advocate to propose and position educational activities for product awareness, acceptance, and utilization”
Services include “Validation of scientific and promotional messages” UMDMJ Center for Continuing and Outreach Education

Advertising in medical journals

5 of 6 physician organizations raised at least10% of annual revenue from advertising in affiliated medical journals
More than 95% of ads in JAMA are for Rx drugs
Pharma companies also purchase “sponsored” subscriptions
And are the largest purchaser of reprints

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

What about R&D costs?

Between 1970 and 2005, research and development accounted for between 8.5% and 17. 3% of sales(PhRMA Annual Membership survey 2006)
Pharma spends 3 times as much on marketing as it does on research

Physicians are not the only prescribers

Physician assistants and advanced practice nurses have not received much attention …
But will in the future

Conclusions

More rational prescribing, including increased use of older drugs with well-established benefits and risks, would reduce drug costs
Reducing inappropriate drug use will also decrease adverse effects and benefit our patients
Pharma should not participate in continuing education of health care practitioners

Recommended Books

Abramson, John. Overdo$ed America

Angell, Marcia. The truth about the drug companies

Avorn, Jerry. Powerful medicines

David, Healy. Let them eat Prozac

David, Healy. The antidepressant era

Elliott, Carl. Better than well

Goozner, Merrill. The $800 million pill

Kassirer, Jerome P. On the take

Moynihan, Ray. Selling Sickness

Mundy, Alicia. Dispensing with the truth

Reidy, Jamie. Hard Sell

Washburn, Jennifer. University, Inc

Organizations

No Free Lunch nofreelunch.org
Healthy Skepticism healthyskepticism.org
Health Care Renewal hcrenewal.blogspot.com
GoozNews gooznews.com
PharmaWatch pharmawatch.blogspot.com/
Center for Science in the Public Interest Integrity in Science Project Integrityinscience.org
American Medical Student Association amsa.org
Health Action International haiweb.org
Consumers International consumersinternational.org

PharmedOut.org

Coming soon!
Funded by the Attorney General Prescriber and Consumer Education Grant Program
We’ll provide news and resources, list pharma-free CME, and provide CME (and hopefully CE) modules on pharmaceutical promotion

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