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. IMS national sales perspectives. IMS Health. 2007 Mar. Table
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 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 May;25(5): 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): 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): Abstract
Lurie N et al. J Gen Int Med 1990;5(3): Abstract
Wazana A. JAMA 2000 Jan 19;283(3): Abstract
**Sigworth SK et al. JAMA Sept 5;286(9): Abstract
McKinney WP et al. JAMA 1990 Oct 3;264(13): 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 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 May 15;146: Full text
**Steinbrook R. NEJM Jun 29;354(26): 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 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 Jan 1;25(1): 70. Full text
**Niles S. Med Ad News 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 Apr 24;4(4):e150. Full text
Elliott C. Atlantic Monthly Apr;297(3): 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”16 16

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 17

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 18

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 19

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 Feb;41(2):52-8. 20

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 Mar 1;7:8-15. Full text 21

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 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 least 10% 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” 24 24

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 Dec;41(12):60-2. Full text 25

26. What about R&D costs?
Pharma spends 2-3 times as much on marketing as it does on research
Edwards J. Brandweek 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. Links to reliable, free drug information
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 or

29. Thank you
References