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Understanding physicians
preference towards
treatment choices
The founding principle
Conjoint methodology
For the last three decades, one key quantitative approach
has enabled us to better understand physicians preference
for treatment options: conjoint methodology.
Introduced by Green and Rao in 71, conjoint studies allow
physicians to view various combinations of product
attributes intended to represent potential target product
profiles (TPPs). After viewing each TPP, physicians are
asked to indicate their level of preference, and/or rank
them based on their likelihood to prescribe.1
In doing so, they offer us some insight into how that
product will perform in-market.
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MARKET RESEARCH MEETS MARKET REALIT Y
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Preference
MD Claimed
Intention Share Peak
% of MDs Calibration Preference
To Prescribe Calibration Share
Factor Share
Factor
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MARKET RESEARCH MEETS MARKET REALIT Y
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MARKET RESEARCH MEETS MARKET REALIT Y
2. Physician adoption: multiple influencing factors What causes some products to be adopted within months
of launch and others to take several years? The variation in
Although physician awareness is driven largely by detailing
physician adoption can be attributed, in part, to certain
reach, the rate to which physicians begin prescribing a new
product characteristics. When it comes to oncology
brand is mainly driven by the characteristics of the product
compounds, our experience shows that adoption rates are
and, to a lesser degree, by detailing frequency.
impacted by many factors, including the number of
A recent analysis of oncology compounds launched in the alternative treatments, tumour type, availability of a
US and 5 European markets since 2003 showed three biomarker test, therapeutic class, and more
distinct trajectories for physician adoption depending on
Number of treatment alternatives: For a first
the market environment and certain product characteristics.
indication, the number of treatment alternatives is one of
On average, peak share for the first indication of these
the most influential factors on the speed of adoption.
compounds occurred around 2.4 years after launch. Others
When the number of competitive alternatives is limited to
followed a more traditional 5-year-to-peak trajectory. A
two or less, physicians begin prescribing the new drug
proportion of these brands, however, achieved peak share
quickly and peak sales are generally achieved in under two
for the initial indication in less than 18 months.9
years. However, when a new drug enters a crowded
marketplace and offers little improvement in either efficacy
or safety, physician adoption is inevitably slower. Under
these conditions, achieving peak sales can take upwards
of three and a half years.10
Tumour type: Tumour type also plays a role in
determining how quickly physicians adopt a new oncology
drug. Newly-approved drugs to treat solid tumours reach
peak share in approximately 2 years, while drugs to treat
haematological cancers take nearly a year longer.11
Availability of a biomarker test: Similarly, the
availability of a biomarker test to predict the likelihood of
response to certain drugs also impacts the rate of physician
adoption. Whilst the introduction of biomarkers into the
marketplace has allowed physicians to better segment their
patients, it also appears to slow physician adoption down.
Source: Ipsos Healthcare Global Oncology Monitor A drug with a biomarker test typically takes about six
months longer to reach peak share than one without a
qualifying test.12 One hypothesis for this is that the
biomarker pre-empts physicians from using that drug for
all patients, and there is a time lag between testing and
treatment for those specific indications.
Therapeutic class: Finally, the rate of physician adoption
can also vary by therapeutic class. Historically, physicians
have more readily started prescribing new products for
diseases in which there is a visible symptom that can be
monitored to ensure the drug is working and, of course,
when there are limited consequences if the product does
not perform in line with clinical trial results. After 24 months
in-market, over 40% of physicians who were aware of new
drugs for pain management and birth control had prescribed
the product for at least one patient; by contrast, only 24%
of the physicians who were aware of new respiratory and
metabolic products had ever prescribed them.13
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MARKET RESEARCH MEETS MARKET REALIT Y
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4. Product affordability: growing in importance This holistic approach would be further complemented by
the inclusion of a patient component; sufferers of the
Finally, product affordability is emerging as a more
condition treated by product X can provide feedback around
meaningful market barrier in both developed and emerging
their willingness to accept certain prices that are tied to the
markets. Below are just a few of the pricing and
tier statuses already being modelled. The integration of
reimbursement policies that have recently been put in place
these three factors physician feedback, payer probabilities
around the world; they point to the growing concern about
and patient price elasticity provides the most complete
the affordability of pharmaceuticals:
picture of how product affordability will impact preference
Healthcare reform legislation passed and currently share and a subsequent US-based forecast.
being implemented in the US
Outside of the US, however, barriers created by product
A freeze on prices for three years in Germany (from affordability may be more straightforward; many
August 2010) governments dictate which products will be reimbursed
2.5% price reduction on generics and introduction of under the national healthcare system and which ones will
generic tenders by AIFA in Italy not. Moreover, if a brand is included on a National
Introduction of mandatory 7.5% price cuts on Reimbursement Drug List, there is typically little to no
innovative drugs provided through the public health expense to the patient and subsequently, product
system in Spain affordability is 100%. By contrast, if the government has
not agreed to reimburse it, the patient bears the full
In many cases, new and expensive specialty drugs are expense and product affordability may become the most
either denied reimbursement coverage by national influential barrier of all.
healthcare systems and private insurance plans, or linked
to high out-of-pocket co-pays by the patient. In such cases, Lets take China as an example: as of 2009, Chinas National
many physicians will opt for a more affordable brand that Reimbursement Drug List (NRDL) included 2,127 medications,
will cause less financial burden to the patient. of which 1140 are Western Medications.14 For these 1140
drugs, product affordability is not a barrier; the Chinese
In the US, the impact that a new drugs formulary position government has negotiated pricing with each respective
will have on prescribing is most easily approximated through manufacturer to enable the cost of the medication to be
primary market research. The questionnaire is structured covered by the national and/or provincial governments.
such that physicians are initially shown the base-case TPP, However, as multi-national pharmaceutical companies
and instructed to assume the product will have full market continue to expand distribution of their branded products
access. After exposure, physicians are asked to record their into China, many will not be granted placement on the
preference share for this scenario. Subsequently, they are NRDL. The desired price will exceed what the government
asked to assume that the TPP remains the same but with the can pay, or acceptable generic alternatives will be available.
formulary status changed to one of four scenarios: Tier 2 (no Then, in other cases, the product may eventually be added
restrictions); Tier 2 (with restrictions); Tier 3 (no restrictions); to the NRDL but will have to wait until the Ministry of Health
Tier 3 (with restrictions). The four reimbursement scenarios reconvenes to review all new drug applications and amend
are rotated and the physician is asked to record his or her the list. It is therefore imperative to understand the likelihood
preference share after viewing each scenario. In some cases, and timing of a new products inclusion on the NRDL as
the formulary access scenarios may be segmented with more well as the proportion of patients willing to fill the
granularity to reflect various restrictions such as fail-first prescription if they have to pay cash for it. Without this
policies or prior authorisation policies. knowledge, preference share becomes just that: a preference
Using this exercise, it is possible to gauge how much the that may or may not be reflected in the marketplace.
products formulary position will impact physician Clearly, when a manufacturer suspects there is a chance
prescribing. This information is most useful when responses that a new drug will not be granted reimbursement they
to the four scenarios are weighted to match the formulary need to be forearmed with market research that will help
access that the pharmaceutical manufacturer expects to them estimate the impact on sales. The best route is to
achieve. However, manufacturers expectations are, at best, approximate the extent to which this will be a barrier to
a biased estimation of a products likelihood to land on any physician preference share by conducting primary market
one tier. A less biased approach is actually to survey medical research among patients. We can then understand patients
officers who serve as the decision-makers around pharmacy willingness to fill the prescription at various price points, and
benefits. By gauging their estimation of a products the resulting price elasticity curve will serve as the means of
likelihood to fall on a certain tier, we can define a probability discounting preference share when the price is set.
curve to use in Monte Carlo simulations of the forecast.
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MARKET RESEARCH MEETS MARKET REALIT Y
Conclusions References
A work in progress 1. Green, P.E. and Rao, V.R., 1971, Conjoint measurement for
quantifying judgmental data Journal of Marketing Research,
It seems clear that the barrier approach to discounting 8:355-363
preference share has significant advantages over traditional
2. Sobel, K., &Bodsky, J., 2008, Translating preference share
preference share conversion methodologies; these can be into market share: rules of thumb that really work, In:
summarised as follows: PMRG Annual National Conference 2008, 9-11 March,
1. Each of the factors causing a reduction in preference Phoenix, US
share can be examined according to the specifics of the 3. Ziment, 2008, Calibration of preference share, In: 2008
individual product: the characteristics of the drug, the Pharmaceutical Management Science Association
level of promotional support that will be put against it, Conference, Las Vegas, US
and the competitive market situation it will be entering. 4. Data from Ipsos Healthcare Sales Force Effectiveness
Monitor, Jigsaw
2. When a range is used for each barrier, a sensitivity
5. Ibid
analysis can be performed to determine the barriers that
are likely to have the greatest impact, either reward or 6. Ibid
penalty, on brand share depending on the manufacturers 7. Ibid
marketing plans. 8. Ibid
3. By outlining the specific assumptions around each barrier 9. Data from Ipsos Healthcare Global Oncology Monitor (US
& EU)
that the brand will encounter in-market, there is
transparency around the rationale for discounting 10. Ibid
preference share. (This may facilitate better 11. Ibid
understanding and alignment among the broader 12. Ibid
business team regarding why preference share is being 13. Ibid
discounted and by how much.) 14. IMS Market Research Consulting, The 2009 Revision of the
4. All of the barriers described in this approach can be National Reimbursement Drug List (NRDL), (Online),
tracked after the product has been launched making Shanghai, Available at http://www.imshealth.com/
it easy for the market researcher to compare actual imshealth/Global/Content/Document/2009_Revision_
NRDL.pdf) (Accessed 5 August 2011)
results against the projections, and adjust market share
expectations if necessary.
Of course, while this method offers advantages over
standard conversion approaches, it is not perfect. In many
cases there will be an inter-relationship between the
various discounting barriers. For example, those physicians
not being detailed and who are unaware of the brand may
be employed at institutions where the product does not
have distribution. In a perfect world, we would be able to
estimate exactly how much overlap exists to ensure that
we discount without double counting. However, given the
data currently available to researchers, it is unlikely that a
precise prediction of all inter-relationships among all the
barriers can be known. Accordingly, the researcher may
need to rely on ranges for each of the barriers.
To conclude, incorporating the impact of market barriers
is a significant step forward in discounting preference
share. However, precise prediction will only be achieved
through continued research into, and evolution of, our
discounting approaches. Until then, the barrier approach,
with its grounding in both market research and market
reality, is an important addition to the pharmaceutical
forecasters arsenal.
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kim.morneau@ipsos.com