The Physician-Pharma Relationship

1. The Physician-Pharma Relationship PharmedOut.org Georgetown University Medical Center January 2008

2. The Physician-Pharma Relationship • Is very old and very close • But are the goals of pharmaceutical companies and medicine the same?

3. Promotion includes • Detailing • Meetings and events (dinner meetings, CME, rounds, symposia) • Publications (symposia, monographs, supplements, throwaways) • Advertising and reprints • Direct mail, e-detailing

4. 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

5. 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

6. 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

7. 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

8. “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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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

15. “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)

16. “I only see reps for the samples”

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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

24. “I Never Read the Ads”

25. 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

26. 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.

27. 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

28. 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.

29. Thank you References