Take a look at lipid-lowering agents. This therapeutic class is extremely crowded and noisy, with several Big Pharma companies backing extensive selling efforts and DTC promotion. Formulary access varies widely by product. Most MCOs place Lipitor (atorvastatin) and Zocor (simvastatin) on preferred status, while Crestor (rosuvastatin), Vytorin (ezetimibe/simvastatin), and Zetia (ezetimibe) are most frequently non-preferred brands on patients' formularies. This category also has one generic—lovastatin (Mevacor)—and will soon have two others, simvistatin and pravastatin. In some markets, notably California, payers require step therapy with generic lovastatin, while other insurers encourage the use of the generic through low or no co-pays.

Using longitudinal patient data for California, manufacturers see the obvious impact of Pacificare's and Aetna's preference for lovastatin, most notably on Crestor and Zocor. AstraZeneca and Merck clearly know that their market share is lower in California, and possibly in these two payer accounts. However, without understanding how altering their promotional effort will affect prescribing, neither company will risk changing their detailing effort from the national norm. (See "California: MCO Shakedown".)

However, when this longitudinal data is combined with ImpactRx's detailing and "new written prescriptions" information, companies are able to quantify the results of their detailing efforts. (See "Written vs. Dispensed.") Crestor and Zocor are detailed as much or more than other products in the category, but those drugs get a disappointing share of the prescriptions written and filled. The opportunity to affect share performance is simply not available because of physicians' preference for prescribing lovastatin in California.

AstraZeneca and Merck can use these data to identify regional-targeting strategies that maintain their current share with a far lower level of resources. In the case of California, Merck and AstraZeneca could simply cut detail effort to physicians who prescribe a high share of lovastatin, and lose little in the way of scripts. (See "Guiding Physician Targeting.")

Margin- and opportunity-based approaches require an increased sophistication in planning and execution. Most companies will resist implementation because it requires them to tap into parts of their businesses they never understood, through data they mostly have never used. There are other challenges. Limitations in available data mean the opportunity-based approach now works best at the state or MSA level. (But better information is set to become available from CMS under Medicare Part D, making this approach more practical on a lower level of geography.) In addition, these approaches require companies to adjust many core business processes, such as physician targeting, which they've institutionalized around volume, and which don't incorporate measures of profitability in reps' compensation program. Assuredly, there will be pushback from both sales management and operations before these value-based approaches can be adopted.

Perhaps the greatest challenge will be getting the three silos—brand management, sales management, and managed-markets organizations—to develop a common understanding of this model. However, companies that are successful can direct savings into higher-return activities, such as the health outcomes research that will be increasingly demanded from the largest and most circumspect payers.

Mason Tenaglia is managing director of The Amundsen Group. He can be reached at mtenaglia@amundsengroup.com
Patrick Angelastro is senior vice president, strategic development at ImpactRx. He can be reached at pangelastro@impactrx.com