PM360 OCTOBER 2010

PHYSICIAN POV

Trickle-Down Marketing to Primary Care

MATTHEW MINTZ, MD, FACP

Serving as a KOL and adviser to several pharmaceutical companies while practicing primary care in the trenches, I’ve had the opportunity to observe their marketing campaigns from conception to promotion.

I am continually amazed that many pharmaceutical companies continue to use antiquated methods when promoting products to primary-care physicians. The prevailing concept seems to be that if a company can get specialists on board, then primary care will eventually follow. This “trickle down” marketing model is propagated by using specialty KOL physicians to assist in the development and delivery of promotional messages. Years ago, this method was probably effective. It likely took several years of seeing psychiatrists use Prozac to treat depression before primary-care physicians initiated treatment on their own. However, back in those days, pharmacotherapy for depression was a fairly new modality. Now prescribing medications for anxiety or depression in the primary-care setting is commonplace. Today’s primary-care physicians are adept at using multiple medications to treat chronic diseases in the context of complex psycho- social issues and insurance barriers. In other words, when it comes to chronic diseases, the PCP—not the specialist—is the expert.

Promotional presentations designed and delivered to primary-care physicians by specialists have diminished in value because the needs of the PCP (simple, easy) and the patients seen by the PCP (complex, multiple diseases) cannot be adequately addressed by specialty physicians. As a PCP speaker, I have found interactions with my primary-care colleagues productive because I can relate to their daily experiences and provide useful advice.

The Wrong Target

The best example of the failure of the trickle-down approach is Pfizer’s inhaled insulin Exubera, which was pulled from the market not due to safety or efficacy issues, but because no one was writing prescriptions. Pfizer relied on endocrinology KOLs who never saw the value of inhaled insulin. Most endocrinologists will tell you that initiation of injectable insulin is easy and PCPs too often fail to do this. However, patients who see an endocrinologist likely have been told by the PCP many times that they need insulin, likely have failed multiple attempts to avoid insulin, have scheduled an appointment with the endocrinologist, and have arrived at that appointment with referral in hand.

In other words, the endocrinologist sees a very different patient than the PCP does. My patients want to avoid injectable insulin at all costs. “Doc, anything but the needle.” “Doc, Aunt Bessie got started on insulin, and then she died.”

Primary Care Perspective

As a PCP who treats a lot of diabetes, I found Exubera to be a godsend. One of my patients finally quit smoking to avoid injectable insulin, since smoking is contraindicated with Exubera. Rather than focusing on endocrinologists, Pfizer should have worked with PCPs on the barriers to using their product, using PCP KOLs to assist with the development and delivery of their marketing messages. One of the main barriers to Exubera was the need for spirometry or lung function tests, an incredibly useful tool that is often neglected in primary care. Ironically, Pfizer had Chantix (for smoking cessation) and Spiriva (for COPD); a spirometry initiative in primary care could have enhanced sales of both these products while helping to break down this barrier pre-Exubera launch. Yet when using specialist KOLs, pharma is more likely to think organ/disease specific, while ignoring the whole picture.

Though many agents coming out will be biologic products used in niche populations where the trickle-down approach will still be effective, many products newly available or in the pipeline focus on chronic disease. If I were a brand manager of a product meant for use in the primary-care setting (for asthma, COPD, diabetes, hypertension, dyslipidemia, or obesity, to name a few), before focusing on the specialists and hoping their adoption will trickle down, I would establish a core group of primary-care KOLs to assist with my marketing strategy and the delivery of my promotional programs.

Dr. Mintz is Associate Professor of Medicine and Director, Primary Care Clerkship, at George Washington University School of Medicine in Washington, DC. Contact Dr. Mintz at his blog, www.drmintz.com