WITH vast and profitable markets up for grabs, drug companies are
aggressively reaching beyond doctors and taking their marketing
messages directly to consumers.
Some of their promotional strategies have become hard to miss. Nightly
news broadcasts — a beloved habit for aging Americans — are brought
to you by the makers of prescription medications for high cholesterol,
arthritis, Alzheimer’s disease and erectile dysfunction; an Internet
search for a specific symptom, or a visit to any popular health site,
will bring up sponsored links and blinking ads for at least one
prescription medication used to treat that symptom; fans of NASCAR see
Viagra advertised every time No. 6 Mark Martin’s car rounds the track.
And women paging through a magazine for tips on reducing clutter can
scarcely avoid the faces and personal stories of actresses who are
managing their depression, osteoporosis or hot flashes with a
brand-name pill.
In 1997, the FDA loosened regulations governing the advertisement of
prescription medications directly to consumers. The change set off
explosive growth in marketing aimed at a general audience long on
interest and — compared with physicians — short on professional
skepticism. Today, drug makers spend roughly $5 billion a year to run
advertising campaigns that use many of the same appeals that marketers
use to sell breakfast cereal and toothpaste.
A study published in the Annals of Family Medicine’s January-February
issue analyzed the messages of 38 advertisements then running during
prime-time TV and found that 95% used emotional appeals to sell the
medication, often framing prescription-drug use as a means to regain
lost control over some aspect of life. None mentioned lifestyle change
as an alternative to product use, although roughly 1 in 5
advertisements suggested it might be a useful complement to the drug.
One in 4 described the causes of the disease the advertised drug
treats, who is at risk for it or how frequently the condition occurs
in the population. The study’s authors, led by UCLA researcher
Dominick L. Frosh, suggested that without such information, consumers
would have little reason to see prescription medication as a solution
that involves risks as well as possible benefits.
In all, 58% portrayed the advertised drug as a medical breakthrough –
a pharmaceutical twist on Madison Avenue’s “new and improved” message.
“It is time to ban direct-to-consumer advertising of prescription
drugs,” wrote Dr. Kurt Stange, editor of the Annals, in an
accompanying editorial. The advertisements consumers see “distort the
relationship between patients and clinicians. [They] manipulate a
patient’s agenda and steal precious time away from an evidence-based
primary care clinician agenda that is attempting to promote healthy
behavior, screen for early-stage treatable disease and address mental
health.”
Even after 23 major pharmaceutical companies agreed to a new slate of
voluntary guidelines limiting their advertising, Stange wasn’t buying
it. Self-monitoring, he wrote, “is not working . . . and cannot
realistically be expected to work.”
PhRMA, the drug manufacturers’ industry group, says direct-to-consumer
advertising empowers patients to take an active role in their
healthcare and spurs them to discuss symptoms, diseases and treatment
options with their doctors that might otherwise go unraised. The
industry group frequently cites a 2002 survey of consumers that found
that 43% were spurred by a prescription-drug ad to look for more
information about the drug or their health.
Although direct-to-consumer advertising has spurred the most political
and professional debate, it is only the most visible means of
prescription-drug marketing aimed at the consumer. To build markets
and encourage consumer loyalty to their products, drug makers have
invested heavily in a tactic known to public relations professionals
as “third-party marketing.” Through voices, groups and activities that
seem independent of them — but frequently are not — drug companies
have found another way to get their messages to consumers.
‘Third-party’ approach
ACCORDING to an article published in the British Medical Journal in
2003, the top five public relations firms specializing in healthcare
earned $300 million in 2002. These firms “are expert at ‘third-party
technique’ — helping the drug industry separate the message from what
could be seen as a self-interested messenger,” wrote authors Bob
Burton and Andy Rowell.
Last October, a commentary in the New England Journal of Medicine
detailed one little-noticed third-party marketing venture.
Underwritten by Eli Lilly, the campaign was designed to increase the
use in hospitals of a drug commercially known as Xigris, for the
treatment of sepsis, or blood poisoning. A preliminary study had
suggested some safety concerns with Xigris, and an FDA advisory panel
had urged more thorough study of the drug before its approval. But in
2001, the FDA approved its entry into the market. The controversy
appeared to sap first-year sales of Xigris, which fell short of
Lilly’s expectations.
Lilly’s response was to secure the services of a small public
relations firm, New York-based Belsito and Co. Belsito would begin
spreading the word to physicians and media outlets specializing in
medical news that Xigris was being rationed and that physicians were
being “systematically forced,” because of the drug’s high cost, to
decide which patients would live and which would die. A $1.8-million
educational grant from Lilly would fund the creation of a group of
physicians and bioethicists — named the “Values, Ethics and Rationing
of Care Task Force” — to study this rationing and its ethical
implications. And a Surviving Sepsis campaign was launched “in theory
to raise awareness of severe sepsis and generate momentum toward the
development of treatment guidelines,” wrote Dr. Peter Q. Eichacker and
two fellow investigators based at the National Institutes of Health,
in the NEJM.
Lilly’s financial inspiration of the campaign aimed at physicians,
patients groups and the media was not apparent to many of the
audiences reached. But its effect was quite clear, concluded a case
study of the campaign done by the Council of Public Relations Firms:
Sales of Xigris “have begun to trend upwards. Through the first
quarter of 2004, Xigris sales were up 36%.”
In such campaigns, public relations companies operate as off-site
extensions of a drug company’s marketing department. But sometimes,
the relationship of a drug company and a third-party voice is more
complex. The tie between patient-advocacy groups and drug companies is
a good example.
Drug makers richly support the nation’s proliferating patient-advocacy
groups, and only a handful of the charitable organizations refuse the
sponsorship of pharmaceutical firms, says Georgetown University’s Dr.
Adriane Fugh-Berman, who has studied these ties. That link presents
rich marketing opportunities for corporate sponsors with an interest
in reaching the patients the organizations advise and represent,
Fugh-Berman says. But it also raises real questions about the
independence of patients groups, she adds.
In marketing trade publications, the value of patients’ groups is
widely touted. As friends and allies to potential customers, groups
dedicated to patients who suffer from a specific condition can be
powerful marketing tools. Patients seek information and emotional
support from these groups, and trust them as an unbiased source of
advice. Groups that empower patients to seek treatment are eager to
foster awareness of their disease and, in the process, expand their
membership. When they are successful, patients groups have a natural
market-building effect.
But drug makers have the deep pockets, and patients groups — until
they’re very large and well-established — are constantly scrambling
for money. As a result, according to those calling for reform, the
relationship is not always an alliance of equals.
“There’s an inherent conflict of interest,” says Merrill Goozner,
editor of Integrity in Science, a publication of the Washington-based
watchdog group the Center for Science in the Public Interest. “The
question becomes, ‘Are you doing the best for the patients you
represent, or are you doing the best for your sponsors?’ ”
Goozner says that patient-advocacy groups are especially vulnerable to
carrying drug companies’ messages, untempered by skepticism, directly
to their members. “They’re desperate” for a cure or treatment, he
says. “And no one likes to be told that this latest breakthrough is
not all it’s been cracked up to be,” especially when it’s being pushed
by a company that’s been generous with funding, he adds.
Last October, the magazine New Scientist published a survey gauging
the dependence of randomly selected U.S. patients’ groups on drug
manufacturers. Combing through the tax returns, annual reports and
voluntary disclosures of 29 nonprofit patient-advocacy groups, the
publication found that most accepted financial backing by companies
developing or producing drugs used to treat patients supported by the
group. In some groups, such as the American Heart Assn., the drug
makers’ financial backing was huge ($23 million in 2005) but
represented a small portion (4%) of revenue. For seven groups,
donations from interested drug companies represented more than
one-fifth of revenue. The Depression and Bipolar Support Alliance said
it received more than half of its 2005 funding from the drug industry,
and the Colorectal Cancer Coalition got 81% of its funding from drug
makers.
New Scientist’s probe found that some donations appeared directly tied
to marketing interests. In 2003 and 2004, when the drug giant Pfizer
was developing a drug to treat restless leg syndrome, it was a major
donor to the Restless Legs Syndrome Foundation. But in 2005, after
Pfizer announced it had abandoned development of the potential drug,
its donations to the patient group dried up.
Many of the best-known groups, including the Alzheimer’s Assn.,
American Cancer Society and American Diabetes Assn., typically have a
board of physicians who vet the scientific accuracy of the information
they provide to patients. And most solicit “unrestricted” grants that
allow them freedom to use the drug makers’ donations as they see fit.
But even large groups often provide a gateway to the products of
corporate sponsors, say those who have surveyed them. Many list
FDA-approved medicines available to treat the disorder that is their
focus and provide Web links that lead patients directly to marketing
sites. And many offer their corporate sponsors access to their
members, a potential gold mine of direct-marketing opportunity.
The corporate-donor pitch posted on the website of the national
infertility patient group, Resolve, is typical of many patient groups.
“Whether you become a site sponsor, a resource partner, or a sponsor
of Resolve’s chats, [the group’s website] is the ideal place for your
company to market its products and services to thousands of men and
women across the country,” the appeal states. Among the benefits the
group lists for becoming a member of the group’s “Corporate Council”
are access to data on utilization of the group’s programs and services
and “the opportunity to establish topics and sponsor special briefings
for patients, the medical community and public policy makers.” Serono
and Organon, both makers of prescription medication used to treat
infertility, are among the group’s corporate sponsors.
Patient groups also mobilize patients — sometimes armies of them –
to push for coverage of prescription drugs by insurance companies and
states’ Medicare and Medicaid agencies. To pharmaceutical companies,
this can make or break the market prospects for a new drug because 80
million Americans — among them, the heaviest prescription-drug users
– receive healthcare coverage through Medicare and Medicaid, and
roughly 155 million have prescription drug coverage through private
insurance companies.
Strength in numbers
WHEN insurers balk at reimbursing patients for new prescription
medications, these groups typically swing into action, rallying
sufferers to appear before public and consumer panels, contact
lawmakers, and provide media outlets a human face to attach to a
cause. Infertility patients mobilized by Resolve, for instance, have
been extremely effective in extending states’ insurance coverage of
infertility treatments. Groups such as the Depression and Bipolar
Support Alliance have fielded experts and patients who have done the
same for psychiatric conditions. And a wide range of patient groups,
most with substantial backing from the makers of erectile dysfunction
drugs, have mounted successful campaigns to get wary insurers to cover
drugs such as Levitra, Viagra and Cialis.
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