Articles

June 2004 Table of Contents

Our industry can succeed only by collaborations," a biotech CEO recently told 

, "because no company has the whole of the jigsaw complete-only a piece." Clearly many of his pharma counterparts agree. The web of alliances formed by the top two dozen biotech and pharma companies from 1973 to 2001-at least the 12,500 contracts made public by these firms-is as tightly knit as a linen shirt.	

Meanwhile the strategic significance, complexity, and cost of biotechâpharma alliances are, if anything, expected to rise. Everyone knows why: the "hunger for product candidates," in the phrase of editor Jennifer Van Brunt of biotech deal specialists Recombinant Capital (ReCap). It seems that "virtually all drug developers are raiding each other's shelves," she says. Jim Hall, president of life sciences at advisory firm Wood Mackenzie, says licensing, which accounted for about $65 billion of Big Pharma's revenues in 2002â2003, will probably top $100 billion in three years. As Van Brunt says, "Companies are in-licensing and out-licensing like crazy." 		

The pace of alliance formation generally should decelerate, Hall says, while the average deal size increases. "The days of the small, testing-the-waters deal worth tens of millions of dollars is going away and will be replaced by very large equity investments," he says. According to consultants at McKinsey & Co., up-front payments in therapeutic alliances increased more than sixfold from 1988 to 2002, and average milestone payments soared, from $6 million in the years 1988â1990 to $85 million in the 2000â2002 period. They also found that 65 percent of pharma executives anticipated that alliances would become more complex. As Hall says, the easy deals have been done: "Large Biotech and Big Pharma are looking for ones in real therapeutic areas rather than discovery and early technology."	

Another trend is less frequent and more dedicated partnering. Fintan Walton, PhD, chief executive of PharmaVentures, a UK-based company that helps biotechs make deals, says some pharma companies are effectively saying, "We prefer to work with a few biotech companies we know well over the years rather than reinvent new alliances and new relationships." 	

These developments put a premium on alliance know-how for pharma companies and executives alike. Patricia Martin, executive director of alliance management at Eli Lilly, says: "I've heard the head of our US affiliate tell his leadership team that hands-on experience managing a collaboration will be necessary to be successful because that's the way the environment is going." 	

This article, the second of two parts (see "Dangerous Liaisons," 

, May 2004), discusses the alliance phenomenon, examines failure rates and what they're based on, and suggests ways pharma can improve its results. 	

"A dance between an elephant and a flea" is how Ed Saltzman, president of biopharmaceutical consultancy Defined Health, describes the typical biotechâpharma alliance. Size discrepancies aside, why would different species care to tango? Simple. Each has something the other wants. But instead of buying, they borrow. And rather than take control, they share. 		

Companies ally when certain conditions apply, says Professor Ben Gomes-Casseres of Brandeis University: (1) They have a capability their proposed partner values but does not have (and could not develop), and the partner has a capability they want but do not have (and could not develop). (2) It would cost more to buy these capabilities than to ally them. (3) It would cost more to merge the companies than create a series of alliances. (4) Combined, the capabilities are more valuable than apart.	

Alliances can serve almost any purpose, from marketing to production and geographic expansion to R&D. However, the needs that prompt companies to seek partners are generally ones that can't be fully specified. The product or capability may not even exist. A complete contract can't be written.	

Alliances manage this problem by operating under an an open-ended contract (also described as incomplete, relational, or evolving) that refrains from spelling out every aspect of the final objective and how it will be achieved. Rather than pin down each partner's behavior beforehand, it obligates them to coordinate and decide matters jointly as events unfold. 	

An incomplete contract need not be vague, Gomes-Casseres says. "You set down as much as you can about the various rights and responsibilities in the relationship. But you realize it will stand or fall on the partners' ability to come up with answers to questions they haven't thought about before." The heart of a relational contract is a commitment closer in spirit  to what binds friends, family members, and spouses than typical business partners. The prevailing attitude is, as the song goes, "we can work it out."	

One way to see how unusual alliances are is to compare them to acquisitions. According to Professor Mike Peng of Ohio State University,"Alliances work well when the ratio of soft to hard assets is relatively high, while acquisitions are preferable when such a ratio is low. Alliances create value primarily by combining complementary resources. Acquisitions derive most value by eliminating redundant resources." And, "consistent with real options thinking, alliances are more suitable under conditions of uncertainty, and acquisitions are more preferred when the level of uncertainty is low." 			

The various kinds of alliances-co-marketing programs, one-way licensing agreements, R&D contracts, strategic supplier relationships, cross-licensing, minority investments, cross-shareholding, joint ventures-can be arrayed along a continuum with nonalliance activities-with spot market transactions at one end and corporate mergers and acquisitions (M&A) at the other. (See "Collaboration Continuum.") The collaborative structures, moving from left to right, are characterized by increases in organizational interdependence, control, up-front costs, and time, and a decrease in flexibility. 	

Alliances fall into two classes, contract and equity-based, occupying opposite ends of the continuum. Contract-based alliances, like the one between Abbott Laboratories and Cambridge Antibody Technology (discussed in part one) are generally formed for a specific purpose for a limited time and entail a relatively low level of inter-firm involvement. Equity-based alliances (for example, the recently announced arrangement between GlaxoSmithKline and Theravance, also discussed in part one) tend to be more open-ended and usually inspire higher levels of interaction. (A contract-based alliance, despite the name, is still governed by an incomplete contract.) 	

The chief benefit of alliances is risk management. Firms deal with uncertainty in three ways, says Gomes-Casseres. They can postpone action, curb the cost of negative outcomes, or "influence the uncertainty itself." Alliances, he claims, accomplish all three: (1) They allow firms to hold off making premature bets by making "incremental commitments to an unfolding strategy," comparable to traversing a stream via stepping stones (the logic behind real option reasoning, exemplified by GSKâTheravance). (2) They let firms diversify risk by sharing it. (3) They create new responses to underlying uncertainties-technological, market-related, or competitive-by joining the collaborators' strengths. 		

But alliances also entail a tradeoff. You reduce performance risk in exchange for taking on a new kind: relationship risk. "You now have to manage something with an outside party," Gomes-Casseres explains. "You don't control them. You have some rights, some sharing of decision making. But clearly you don't have the full latitude you have when you control all the pieces." 	

For all their purported value and importance, strategic alliances pose two persistent puzzles: (1) Most fail. Numerous surveys say 50â70 percent in every industry don't meet expectations, raising the question: Why bother? (2) Most seem to fail for controllable reasons. Even when undertaken as a hedge against technological uncertainty, the reasons for failure most frequently cited by participants are nontechnological-culture, communication, leadership, strategy. (See "Causes for Concern.") This raises another question: If managers could do better in these areas, wouldn't alliances succeed more often? If so, then aren't resources-time, money, personnel-being squandered? 			

Yes, says Stuart Kliman, co-founder of relationship consultants Vantage Partners: "A huge amount of money and time are wasted." Hall recalls that the cost of poor alliances was in the tens of billions of dollars several years ago.	

				Maybe so. But there may be less to reported failure rates than meets the eye: 	

 It's hard to say what a failed alliance is. Are technical failures included? Can technical and nontechnical failures be distinguished? Kliman suggests that breakdowns in the working relationship can 

 technical failure. How do you weigh relative and absolute failure, the difference between disappointment and disaster? Are a partnership's stated objectives to be taken at face value? What if they're unrealistic? What if an alliance meets its goal but is terminated-on schedule? What if it doesn't meet its goal but achieves some other benefit? Is it a failure?	

 The verdict on an alliance can be asymmetrical-one partner gives it a thumbs up, the other is less kind.	

 What does a single number mean? Most business startups fail. Most mergers and acquisitions fail. And most drug leads don't pan out. So what if most alliances fail? When someone told science fiction writer Theodore Sturgeon that 90 percent of science fiction is "crud," his response-since enshrined as Sturgeon's Law-was "90 percent of 

 It's "difficult to establish a true failure or termination rate," says Michael McCully, director of consulting at ReCap, "because companies tend to 'bury their dead at night.'" Even his company's database of 18,000 deals does not have "good numbers on alliance termination rates because we don't have enough good information." 	

Deciding to form an alliance may not necessarily be daft. Still, there's plenty of room for improvement in the doing. 	

Alliances fail for a multitude of reasons. Whatever can go wrong, will. Companies get stuck with a bad match, a partner that is a poor strategic, organizational, or cultural fit. They drag out negotiations or saddle themselves with onerous terms. Hall recalls a $60â$70 million, five-year deal between a large pharma and medium-sized biotech to develop a therapeutic franchise to plug a gap in the former's portfolio. "It fell apart," he says, "when the biotech found that the more 'successful' the alliance became, the more money it would lose. The terms were beneficial when they were a small startup. They just never thought they'd grow up." Companies can suffer from partner opportunism or poor governance. They can also lose the "learning race," the contest to unlock their partner's bag of tricks (firm-specific resources and capabilities) before the partner figures out theirs.				

Patricia Martin, executive director of alliance management at Eli Lilly, believes alliances fail because: (1) The science doesn't work. (2) The scientific decision isn't good because the communication isn't good. (3) There's no hope of a scientific decision, good or bad.	

The last two are just the sort of factors one would expect partners could minimize. But if the research is to be believed, the situation has actually worsened. In 1999, three of the top eight reasons for alliance failure (see "Causes for Concern") were external. By 2003, just one is. Only "drastic changes in business environment," doesn't indict the executives involved.	

But perhaps these figures deserve skepticism. Gomes-Casseres wonders, "When managers report that 'our cultures didn't mesh,' what does that mean? It could mean we had a conflict of interest and didn't see eye to eye. It could mean we spoke different languages. It could mean we had different decision-making protocols. To use a large term like culture or trust as an excuse for failure lumps it into a large category that doesn't tell you what's going on."	

Shallow analysis is not the only problem. Though not obviously self-serving, these self-incriminating lists of failure factors make a habit of omitting some even less flattering possibilities:	

 Economists explain business failure as the expected outcome of a rational decision regarding a risky scheme. But psychologist Daniel Kahneman, winner of the 2002 Nobel Memorial Prize in Economic Sciences, and Dan Lovallo, a senior lecturer at the Australian Graduate School of Management at the University of New South Wales and a former strategy specialist at McKinsey & Co., wrote in the 

 (July 2003): "When forecasting the outcomes of risky projects, executives all too easily fall victim to what psychologists call the planning fallacy"-the product of cognitive biases and organizational pressures-"which leads them to make decisions based on delusional optimism rather than on a rational weighting of gains, losses, and probabilities." Eric Bolesh, senior analyst with Cutting Edge Information, would agree: "At the beginning of an alliance, there's a lot of promise, good feelings, handshaking, backslapping." Folks don't think about what can go wrong, Bolesh says. It's not that they ignore the worst-case scenarios so much as they never consider the "not quite worst case scenarios." 	

"A lot of salesmanship" is required to get a deal done, Bolesh says. Kahneman and Lovallo believe the struggle for project approval raises the odds that the one chosen for investment will be the most overoptimistic-with the highest probability of disappointment.	

Hall calls this "the number one reason alliances fail." Whose ego? "Typically the smaller partner," he says. "The inferiority complex that drove them to the table gets in the way. They're doing a deal because they need the cash, as opposed to because it fulfills their vision of the company." 	

Accepting that most alliances fail (whatever that means and for whatever reason), research shows that not all companies fail at the same rate. A 1998 study by consultants Booz Allen & Hamilton showed some firms had failure rates as high as 70 percent while others had rates as low as 10 percent. What makes the difference?	

To see why alliances fail, it helps to examine them from three angles. Each corresponds to a set of problems and a prescription for success.				

An alliance-level perspective doesn't focus on the individuals or the environment, or one partner or another, but the relationship between them.

 "If folks aren't getting along," Kliman says, "it's because of structural issues." What about culture-whatever that is? "Good management is about figuring out how to handle cultural differences," he insists. "A good working relationship shouldn't depend on an absence of conflict." Alliances are founded on uniting different resources, different views, different capabilities. "The goal is not to eliminate differences," Kliman says, "but to create value out of them, turn them from a liability into an asset."	

Companies that ignore an alliance-level analysis are asking for trouble. One partner's "mixed messages or unresponsiveness" can lead, Kliman says, to "individual behaviors that seem closed or disrespectful-that damage the working relationship and lead to mistrust and poor performance and thus slower decision making, missed milestones, lack of innovation, and, in time, a failed alliance." 	

Relationship management is the solution. Too often, Kliman says, management "thinks smart people will just be able to work it out." They rush into an alliance, hoping folks will figure it out on the fly, when instead, they first need to achieve "clarity about how decisions are made, what kind of information is to be shared, and so on." 	

Relationship management requires organization and preparation. He recommends an "internal launch" that clarifies the team's roles, responsibilities, and operating protocols and "gets internal boundaries effectively managed." The next step is a "joint launch" that brings the right people from both sides to the table to talk about how they'll handle problems.	

Firm-level analysis brings a company's collaborative capabilities to the fore.

 The ad hoc approach sees alliances as a string of unique relationships. But there's a better approach, one that focuses on systematic alliance capabilities that transcend particular partnerships. That means creating tools, templates, and processes, and inculcating an alliance mindset throughout the organization-just what Eli Lilly has done. (See "Lilly Promotes Alliance Spirit.")	

Successful companies understand that alliances are not peripheral. But neither are they replications or extensions of the company. They are strategically vital and organizationally distinct. Such companies are prepared to commit resources to alliances, to measure, evaluate, learn, specialize, train, and strategize. Many institutionalize their alliance capability by establishing a dedicated alliance management function. Professors Jeffrey Dyer of Brigham Young University, Prashant Kale of the University of Michigan, and Harbir Singh of the University of Pennsylvania compared 203 firms, including a few from Big Pharma, some with and some without alliance management functions. They found that those with alliance functions had a 25 percent higher long-term alliance success rate and generated almost four times the market wealth whenever they announced the formation of a new alliance. Bolesh confirms that almost everyone in pharma that Cutting Edge surveyed said it's important to have someone dedicated to alliance management, "not to do day-to-day project management and get caught up in the commercial or science side, and not to be a high-level white knight within the organization, trying to fix things without really understanding what the problem is, but just having someone there to shepherd the project along, to make sure that management on both sides are speaking, to make sure that senior management, if necessary, is involved, and basically bail the ship out if it starts to get a little leaky now and then."	

Network-level analysis surveys industry structure and competition, forces that compel companies to create constellations of alliances.

 Companies need a map to navigate not just their own web of partnerships but their competitors' and potential collaborators' too. However, as Gomes-Casseres is fond of noting, many of the companies that form strategic alliances lack an alliance strategy. The tragedy is that strategy is what should dictate partner choice, governance structure, and every other aspect of alliances. Strategy even determines what counts as failure or success. It may not be a short-term result. It could even be something other than cash-knowledge, repositioning, or a new product or source of supply.	

To place individual alliances above a coherent alliance strategy is a grave error, Gomes-Casseres believes. "When you start thinking about optimizing the deal instead of optimizing the strategy, you're looking at the wrong target." One symptom, he says, is misinterpreting "the tendency of alliances to change over time as a weakness." The goal of an alliance, after all, "is not its survival but the success of the alliance strategy."	

Features

Our industry can succeed only by collaborations," a biotech CEO recently told Pharm Exec, "because no company has the whole of the jigsaw complete -- only a piece." Clearly many of his pharma counterparts agree. The web of alliances formed by the top two dozen biotech and pharma companies from 1973 to 2001 -- at least the 12,500 contracts made public by these firms -- is as tightly knit as a linen shirt.

Why Alliances Fail

What are the industry's current hiring needs? What functions are most challenging to retain? How do misconceptions about working in pharma affect recruiting? These were some of the questions raised at an exclusive roundtable on pharma industry recruiting, co-sponsored by 

 Job Market. The discussion was moderated by Mary Cianni of Towers Perrin and included representatives from Wyeth, Johnson & Johnson, Novo Nordisk, Sankyo, and HoffmanâLa Roche, as well as the State of New Jersey and Rutgers University. (See "Roundtable Participants.")	

What follows is an edited transcript of the discussion.	

Let's start off by talking about your perspective on the current state of the work force in the pharmaceutical industry. Is it expanding? Contracting? 		

Bradley T. Smith, HoffmanâLa Roche: 

The industry as a whole is very cyclic, but I think the trend has been toward growth. My metric is the difficulty we have competing for talent who have pharmaceutical backgrounds, and the places where I've seen growth have been the commercial areas-marketing particularly-and areas that relate to product development. The rest is flat.	

There is also a lot of movement from one company to another and a lot of challenges in trying to get the top talent to move. Companies like the one I am with are faced with a challenge of focusing primary care physicians on our products. We need to put a lot of emphasis on increasing sales and increasing our presence in the market. So our growth has been about 20â25 percent this year, particularly in sales.	

If I might take an economist's perspective, what we've seen in 2003 is consolidation, some of it out of caution, some of it out of concern for stock prices, and some of it to digest the effects of merger activity in the past. The turnaround we are experiencing now seems in part a reflection of returning confidence to the economy. We probably have more opportunities at the moment than we have people to fill them.	

 And the result is poaching from one organization to the other, because no one has the ability to train entry-level employees. At a time when the market is so critical, you need the best as fast as you can. So we are recycling folks from one organization to the other.	

 Everybody projects growth for the industry. Everybody's got a pipeline that's going to be coming to fruition around 2006â2007. So everybody starts looking at how to plan for that growth. The other thing is that with AventisâSanofi, and all the potential mergers, we see a lot of people putting out their résumés to test what's out there "in case." 	

Bill Healey, Healthcare Institute of New Jersey:

 We just released our annual economic study. Pharmaceutical employment in New Jersey was flat, down by about 700 individuals in 2003. It was interesting to note that the percentage of people in clinical development rose by two percentage points over the previous year, while the percentage of people devoted to corporation administration was down by two points. The sales and marketing category went up by a point. 	

Besides pipeline, what other measures do you use in planning? How do you go about predicting what your hiring needs are going to be?	

You need to look at your work force and your succession. What are your key roles? Do you have backups in your organization who can be trained or who have the experience you need? 	

 Also, strategically, what are your lines of business, what are you going to be getting into, and what are the gaps between the skills you have in your organization and the skills you need? Then how does that play out in terms of experienced hires or college campus hires? 	

 The other thing is to make sure we have a diverse work force. We look at gaps and holes in our organization. If we have a position that is available, we may look for a woman or a person of color to fill that role and come in as an overhire and eventually put them into some specific role, moving more toward a diverse work force.	

We've found some situations where we are doing just-in-time staffing, particularly in our sales organizations, where a competitor is releasing a product and we realize we're at risk with one of our blockbuster drugs, and we'll quickly put another 500 feet on the street. I know we're not the only ones who do that.		

Something else we haven't talked about: We've recently had experience in crossover between pharmaceuticals and medical devices. That's a trend that is simply going to continue. You are going to find pharmaceutical elements in consumer products as well. So you are not necessarily looking for the same kinds of people with the same kinds of experience that you were before. 	

Patrick Clinton, Pharmaceutical Executive: 

You all seem to have a vision of the kind of recruiting you need to do today and the kind you need to do three, four, or five years from now. How does that work? Is it a matter of hiring development people today and looking toward hiring sales force in a few years? Or is it more complex?	

It's really a combination. It's what do you need to hire today so that you can be ready for what you want to be ready for five years from now. What kinds of people do you want to hire today so that you have the leadership that you need five or six years from now? What's the growth period you need to develop those people? You're feeding so many different factors into the mix simultaneously and saying, "How does it work best?"	

 And then think of the churn. We have these people moving around the industry. So how do we retain or develop talent as opposed to just sharing it? I've struggled, throughout my career, to do work force planning in this industry. Pharma is very cyclic. We didn't anticipate three years ago that we would be hiring this many people into the development organization-because we weren't making as many deals then, and now we are. 	

I think in four or five years, there is going to be a tremendous need for commercial, sales and marketing people, and we are going to be up against it. But it's hard to put a stake in the ground today and say, "I'm willing to invest," until we see those products in the pipeline, ready for launch. 	

 How is the image of the industry impacting your recruiting?	

 That's a hard question, because you really don't know how many people choose not to apply. Those who choose to apply have already decided that the industry looks attractive. So that's kind of a chicken-and-egg question.	

 I will say, though, when I was working with some out-placement firms, I had roundtables with people who were either unemployed or "in transition," as they say. They knew I was in the industry, and 99 percent of them said, "I'd love to get into the pharmaceutical industry. How do I get there?"		

 I can give you a little bit of information from the young candidate's point of view. More than half told us that they think the pharmaceutical industry should make more drugs available for poor countries. But that's balanced on the other hand by the perception that the pharma industry has made major breakthroughs in recent years in developing new drugs to cure diseases. They have a mixed view of the industry.	

What are some of the misperceptions people have about the industry?	

We're stodgy, not innovative,  slow. We're bureaucratic and highly centralized.	

People think that the government does the research, and then we take it and commercialize it and make dramatic profits off of it. I think if you went out on the street here today and asked people, "Who does more drug research-government or pharmaceutical companies?" they would say the government, even though we do 95 percent of the research that results in approved drugs.	

I know that since the recent scandals in industry, on college campuses in particular, we have had many more questions. The level has been something that we can't ignore, asking us, "Are you really ethical? We know you have a credo. Is that just something that's sitting on your wall?" It's a much bigger issue than it used to be.	

There is a perception, particularly among children and young adults, that if you go to work in the pharmaceutical industry, you need a background in science and you are going to be working in a lab somewhere. 	

That's how our industry is viewed by the talent pool of the future. So we have to start very early on. The Healthcare Institute of New Jersey has had some great partnerships with a number of companies in bringing in high-school children to say this is not what our industry is all about.	

 Let me build a little bit on that. When Rutgers put in our pharmaceutical MBA program, we discovered that the typical MBA student simply didn't think about pharma, even though it is a major industry in New Jersey. And part of the reason was the misconception that you need a degree in biology, chemistry, or medicine. I think that remains a big issue.		

Second, even if students understand the pharmaceutical industry, they don't see clear career ladders for nonscientists. They say to themselves, "Okay, they'll give me an entry job. Maybe I'll go into sales. If I'm luckier, I'll go into marketing. But where do I go from there?"	

The last piece is the perception of compensation. The average pharma salary here in New Jersey is, give or take, $85,000 a year. But if you look at what top talents can get at a consulting firm, there's no comparison.	

Two years ago that was not an issue. One year ago that was not an issue. It's going to be an issue this year.	

The truth is that there are career paths one can follow that do lead to large amounts of money. But I don't think they are widely understood by the talent you want to attract.	

We have been talking a lot about recruiting. What about retention? What challenges do you face in keeping top talent?	

One issue is internal transfers. We've had to shut down posting because certain growing departments have raided other areas that are critical to getting product out the door.	

We've recently embarked on a program to build internal movement within the company. It has the downsides that Gerry [Geckle] just mentioned. But at the same time, we need to think of ourselves as one, large enterprise and ultimately realize that we benefit when people move around. What is the alternative? To lose them to a competitor.	

At the end of the day, retention is driven by the manager. It's the relationship the employee has with that person. Do they have coaching skills? Can they have a career-interest dialog with an employee, and will that employee be comfortable in being open with them? Is it okay to look outside the department, or is that a breach of loyalty?	

Years ago, there was an issue around loyalty-people who left a company could never come back. That's obviously gone. People move four or five companies in their career and end up where they started. But it is that relationship with the manager that really drives it. You need a manager who is open and wants to help people develop and provides them with opportunities to try new things, different things.	

 What expectations do you have of universities in terms of the training or development they are doing to ensure that talent comes into your industry? Is there a pattern of things missing?	

 I think so. St. Joe's [in Philadelphia] and Rutgers have started to focus more on their marketing programs, specifically on how to market or advertise to a diverse population and how to target specific groups. Most universities don't have that. Vanderbilt and Harvard are now looking at training for clinical trials and setting up clinical design. There are still some gaps when you look at electronic filing, regulatory training, and all of the nuances that go behind that.	

 What I see missing is the whole sociology and psychology of working with people. Students go to school to learn a particular function and come out with a lack of understanding of what it's like to work with a diverse work force. Who am I, and what does that bring to the game, and how do I interact with other people? How effective can I be? The diverse work force-people who are different, who may come from a different country-I see that missing.	

 The pharmaceutical industry is very important for the state of New Jersey, where we're holding this meeting. What does the state do to help companies find the employees they need?	

What are the industry's current hiring needs? What functions are most challenging to retain? How do misconceptions about working in pharma affect recruiting? These were some of the questions raised at an exclusive roundtable on pharma industry recruiting, co-sponsored by Pharmaceutical Executive and the New York Times Job Market.

Hire Expectations

Orchestra conductors may, at first, seem like an unlikely comparison for pharma marketers. After all, a conductor's job is to ensure that each instrument harmonizes with others within the section; that all the sections complement one another; and that the timing, tone, and pitch of each disparate part are flawlessly executed. But when one appreciates the challenges facing executives today in integrating all components into the marketing mix, the analogy seems appropriate.	

Understandably, direct-to-consumer (DTC) advertising is only one movement in the composition. But faced with industry's increasing reliance on DTC to drive preference for the growing number of parity products, consumer marketers' biggest challenge-and opportunity-comes in leveraging the benefit of the whole marketing mix. In doing so, not only can they prompt patients to talk to their physicians, but they can actually influence that dialog, and, ultimately, affect how well patients adhere to and comply with the prescribed regimen. 

 convened a roundtable of esteemed DTC marketers responsible for some of the biggest and most effective consumer campaigns. The discussion revealed the struggle that integration poses to consumer marketers in advancing their craft. But it also highlighted how much these executives have learned since 1997-they are now focused on return on investment (ROI), they are moving slowly and smartly into new tactics and formats, and, by looking to their peers in consumer packaged goods, they have a much better understanding of their target audience. Here's a summary of that discussion.	

In today's information age, consumers, not companies, are leading the integration effort. Patients are connecting the dots between ads they see on television, the magazine story with their favorite celebrity talking about a health issue, and the e-mail newsletter containing tips on heart health. In fact, patients have logically grouped those messages around a brand or disease, and marketers are struggling to keep up. 	

"What always happened, and still happens, is that professional agencies claim the territory of the physician's office and everything else is considered DTC," says Jim Sandino, former president of Lowe Consumer Healthcare, now president of the J. Sandino Group. "Yet the campaign for Accutane, which blurred those lines by putting simple branded devices inside dermatologists' offices, was a very effective tactic to extend DTC into physicians' consciousness and actually right into their office."	

"At the end of the day, you need to put the patient together with the doctor to have that important dialog," says Frank Hone, executive vice-president, global business group, Healthworld Communications. "We have to help guide it. One way we've done that, in the direct response DTC campaign we developed for Avonex, was to include a question card for patients to bring to doctors, which guided the conversation to get the positive outcome we desire."

Inside Information. Andrew Schirmer (right) and Anne Devereux (left) share their insights on what makes DTC advertising tick.	

Roundtable attendees agreed that the lack of a central marketing architect hampers program integration. "It's incumbent on clients to take that leadership position, to bring everyone together and make sure that everyone has an aligned strategy in bringing the brand to market," says Amy Niemann, vice-president of marketing for Barr Laboratories. "Not only the consumer and professional ad agencies, but all of the folks who are working on the business, whether it's interactive, public relations, or medical education."	

Several participants noted that if clients don't drive or reward integration efforts, they simply don't happen. "We did a major product launch for a client last year, and there was all this talk about interagency integration," says Bill Drummy, chairman and CEO of Heartbeat Digital. "We had all the meetings and we did all the right things. Everyone agreed. But with the lead agency dictating the creative, none of it happened. There are very few clients that have the actual insight and the force of will to say to the agencies that they have to come up with a comprehensive campaign and stick to it."			

It may be unrealistic to think that clients have a handle on how to best integrate agencies. More and more, partnerships seem the ideal answer, with companies and agencies trying new ways to bring around a brand-centric, versus a budget-centric, approach.	

BBDO, for example, recently appointed Anne Devereux to the new role of chief integration officer. "Many of us from a holding company and large-agency perspective are creating integrated service networks inside the agencies, so the onus doesn't only fall on the client," says Devereux. "It's worth all the meetings and all the energy to break down those silos because you will see the results in the marketplace."	

Small agencies have created their own networks as well, whether formal or on a project basis. Sandino says the latter approach was effective in creating and launching an integrated DTC campaign for Kremers Urban's omeprazole in less than three weeks.		

Patient Care. Denise Strauss (left) stresses the importance of reaching patients with credible spokespeople. Frank Hone (below) discusses how to effectively create dialog between patients and physicians.	

Integration efforts may also be the key to increasing and advancing persistence and compliance programs.				

"You don't see any more than 10â15 percent of total media dollars spent on compliance and persistence," comments  Michael Guarini, managing director of Ogilvy & Mather's healthcare practice. "For those programs, the industry is just adopting a lot of the standard consumer marketing tactics, like free trial offers or coupons."	

Certainly, environmental forces will dictate that marketers increase their efforts in this area. "There will be intense pressure on price over the next couple of years," says Anthony Manson, senior vice-president, managing director, Sudler & Hennessey. "All companies are going to have to deal with that. All of a sudden, getting that repeat script may be a more viable way to grow the business than the acquisition part. So we may see changes in the pattern of spending in the next couple of years."

Denise Strauss, director of marketing for Bayer Men's Health and Levitra, says new efforts will be more interactive. "The opportunity with compliance and persistence isn't as much with national broadcast media, but it's online and through customer relationship marketing. That's where we'll see an increase in investment with more product managers using those tools to grow loyalty and compliance."	

Marketers should also focus on getting inside conversations between patients and doctors, where the greatest opportunity to change behavior lies. "Industry is extremely limited to incentivize physicians to give out patient support material," says Sandino. "On the other hand, the only patients who voluntarily enroll in compliance programs often need it least. So companies are only getting a small improvement in drop-off rate. It's analogous to everybody going after the two top quintiles of doctors. You need to get to the physicians in the next two quintiles down who are trying to grow their practice. Similarly, we need to get to the not-so-good patients in order to make a compliance program truly effective."	

 "This is where integration is going to be crucial," says Devereux. "Just look at the diagnosis process for a patient with high cholesterol. The doctor says, 'I'm going to put you on this exercise regiment, and if you can't get your numbers down, I'll give you this drug.' So despite all of the patient's best effort, he fails, gets Lipitor, and feels like a loser. What's his motivation to stay on the drug? Until we get into the doctorâpatient dynamic, we're going to have a very hard time hitting the adherence issue on our own. That's why integration is the path of the future."		

The Ins and Outs of Regulation. Anne Myers (left) and Louis Morris (right) talk about the various challenges and opportunities in working with FDA to create new formats for DTC communications.	

New efforts show that to be true. Novartis' most recent "Take Action for Healthy Blood Pressure" campaign highlights integration with messages aimed at the public through an educational initiative and medical education for physicians, and thus creates conversation between patients and doctors using the same language. Also unique is the campaign's money-back guarantee, which drives patients to physicians' offices to get tested and increases compliance.	

In its recent guidance, FDA announced that pharma's help-seeking ads fall outside its purview. That statement has reinvigorated the discussion about unbranded advertising, but may not change companies' strategies.			

"Interest in unbranded advertising is diminishing," says Mitch Roberts, senior vice-president, group managing director, consumer operations for Cline Davis & Mann. "It's very difficult for clients to understand pouring money into unbranded efforts."	

Indeed, DTC marketers often say that awareness is only valuable if it drives consumers to physicians to ask for brands by name. 	

"There's too much data that show  that eight or nine out of 10 patients will get the drug they ask for," says Stuart Klein, president of the Quantum Group. "One of our key challenges is getting that often incomprehensible brand name on consumers' lips because, for the most part, in these parity categories, doctors will write whatever patients ask for."		

Top Priorities. Anthony Manson (right) notes that pharmaceutical companies will direct more money toward persistence and compliance efforts. Stuart Klein (below) discusses the importance of brand awareness.	

Therefore, marketers will continue to use unbranded advertising only when "you have something new to say from an educational standpoint, when it's the only product on the market, or the rare occasion that you do get a unique point of difference-those are the times when help-seeking is effective," says Ellen Fields, group account director at DDB. 	

Richard Czerniawski, managing partner of the Brand Development Network and keynote speaker at the roundtable, challenged that assumption: "If a company wants to have an ongoing dialog with patients, untrademarked advertising-which is anything but unbranded-can be very effective," says Czerniawski. "If people perceive that Viagra is weaker than Levitra and Cialis, I might want to go unbranded to get that dialog going."	

One common advertising tactic to improve the ROI on help-seeking advertising is to link it with a branded reminder spot. "The only way we can make it work for Zocor, which is strong but still distant to Lipitor, is to link them to branded efforts," says Guarini. "Otherwise, we are driving 65 percent of new patient starts to Lipitor."

FDA did warn industry in its guidance against pushing the envelope on pairing disease awareness advertising and reminder ads too closely. "The FDA guidelines will open up new ways in how we use unbranded and branded communications," says Todd LaRoche, executive vice-president/managing director of creative at Palio Communications. "That's where you're going to see some changes."	

One area under investigation is how corporate branding can be used in help-seeking advertising. "When Bob Dole did unbranded advertising for Viagra, you saw a little blue oval at the bottom," says Andrew Schirmer, executive vice-president and managing director for McCann HumanCare. "That was nice synergy, but it was happenstance. The reality is that the two brands can help each other, but that isn't viewed as an objective at the corporate level."	

But change is slow, especially when it comes to trying new things. "DDMAC has always been interested in learning, and they are willing to experiment as long as it fits within the regulations," says Louis Morris, former acting director and branch chief of DDMAC, now president of Louis A. Morris & Associates. "But industry is fearful to approach FDA. When push comes to shove-and plenty of people are pushing, including ad agencies-companies don't want to engage in that kind of risk taking."

Speaking From Experience. Amy Niemann (left) discusses how agencyÃ¢ÂÂclient integration can work. Richard Czerniawski (center) challenges assumption of help-seeking advertising. Jim Sandino (right) provides war stories from several DTC campaigns.	

Yet Eli Lilly's Anne Myers, Strattera consumer marketing manager, says that is not acceptable. "We're all after the same goal-good patient care. If we can think of it that way, as having the same objective, we can get somewhere. If we continue to be afraid, we'll get nowhere."	

The roundtable discussion proved that some of the most important DTC lessons have been learned from the consumer packaged goods industry. 				

"DTC is getting a lot more people from other types of agencies into this category," says Millicent Badillo, senior vice-president, brand director for Cialis, Grey Worldwide. "They're saying, 'I don't know about molecules. But what's the insight here? Why do patients need the drug? Why is it different?'"	

Indeed, consumer insight may be the key to making a brand resonate. "For the Lipitor work, we learned to understand how the target audience truly viewed themselves," says Devereux. "We spent time talking to baby boomers, and we also delved into the MacArthur Foundation Study that showed that baby boomers see themselves 10â15 years younger than they are.	

"When the reality of disease collides with our perception of ourselves, that's when we start tuning out the messages. So featuring people who were cast to look young, healthy, and vibrant is much more aligned with how the audience sees themselves, even though it's not who they truly might be."		

Taking those campaigns to the next level means translating the insight into tactics. "Great tactics also come from really knowing who your consumers are, what they think, what they enjoy, where they work, where they play," says Strauss. "Then talking to them in their language, maybe through a spokesperson who is credible and who is a mentor. It also means reaching people in a venue and talking to them about a product or condition in a way that they haven't heard before." 	

But for many consumer marketing veterans, that is easier said than done. "It's hard to do work in this category that is successful and that is respected by the larger advertising community," says Schirmer. "And it is ridiculously hard to do both together. But the people sitting around this table have stuck with it-pushing on behalf of the client to make sure that it's successful; pushing for the patient, ensuring that it's clear; and pushing as craftsmen, making sure it's something we're proud of."	

Orchestra conductors may, at first, seem like an unlikely comparison for pharma marketers. After all, a conductor's job is to ensure that each instrument harmonizes with others within the section; that all the sections complement one another; and that the timing, tone, and pitch of each disparate part are flawlessly executed. But when one appreciates the challenges facing executives today in integrating all components into the marketing mix, the analogy seems appropriate.

DTC's Next Chapter

Biologics and specialty pharmaceuticals, which typically target small patient populations, have historically necessitated a high per-patient cost to justify their R&D investment and expensive manufacturing and packaging processes.	

But many in the industry are doing unintentional, but nonetheless significant, damage to their companies by perpetuating the belief that these features create a unique set of rules for their products. While that may have been the case in the past, recent market developments have created a different landscape. Still, many companies are not sufficiently taking into account what has changed, and nowhere is it more dangerous than during the development of payer coverage and reimbursement strategies.	

 articles ("Show Us the Value," September 2003, and "Raising the Bar," November 2002), we forecast an aggressive shift in managed markets' policies, predicting they would demand that pharma companies develop and market products that deliver healthcare value commensurate with their cost. Extensive research conducted by The Bruckner Group (		

) has measured a similar and increasingly critical tone in payer attitudes and strategies toward coverage of specialty pharmaceutical products. Unfortunately, the managed market strategies many companies are pursuing for their biologicals do not sufficiently recognize the subtle but unmistakable changes and fail to fully understand their markets and their markets' needs.	

It's understandable that a history of success has led many companies to retain beliefs that have only recently been superceded by market shifts. In 1982, when human insulin was introduced as the first biotech product, and for many years following, payers saw biologics as a panacea, an opportunity to finally treat patients with chronic, progressive diseases. Those first treatments delivered excellent value even at high cost, in part because they addressed specific and targeted needs:				

diseases with relatively small patient populations (under 20,000), such as Gaucher's disease, which lacked alternative treatments

chronic diseases (like hepatitis C and multiple sclerosis) that might be put into remission or possibly even cured

diseases (such as cancer and AIDS) that require rescue therapies and critical care.

Typically, a biological was welcome as either the only option available with a reasonable threshold of efficacy, or as a third-line or rescue therapy in the most refractory cases. Given that the patient populations qualifying for these treatments were relatively small, extremely sick, or both, their high cost-from $10,000 to $100,000 annually per patient-did not preclude usage.	

The US healthcare system was also far less value- and outcomes-driven in the 1980s and '90s than in the present environment. Furthermore, because biologics are often delivered by injection or IV and require more medical oversight, they were typically paid for out of the payers' general medical benefit. By avoiding the intense scrutiny of payers' comparatively smaller pharmaceutical budget, growth of biologic use was relatively unimpeded.	

Fast forward to 2004. Biological products have exploded into the medical therapeutic market: approximately 120 are available and 90 more are on the way. Biologics are now approved for widespread diseases such as psoriasis and rheumatoid arthritis, which affect millions of sufferers. Biologics are treating much wider patient populations than anticipated at an annual cost of $22 billion. According to AdvancePCS, up to 5 percent of a managed care organization's patients are prescribed biologic products. With an annual growth rate of 20 percent (twice as fast as that for pharmaceutical expenditures and three times as fast as overall healthcare) payers are targeting specialty drugs for greater scrutiny and cost control not for their failure to deliver, but because of their success.				

In the last few years, biologics have gradually moved from the medical expenditure budget (where they constituted only 1â2 percent) to the drug expenditure budget (where it is a much more substantial 15 percent). The shift has created a new and obvious cost-cutting target for desperate healthcare insurers. Few in the biotech industry seem to fully understand the implications of having their products scrutinized for pharmacoeconomic robustness, forcing them to compete alongside a wide array of management options and treatment pathways. Regardless of the fact that these products offer something unique and are the result of biotech's high-risk R&D, payers are not willing to accept those noble pursuits as a reason for reimbursing their high cost.	

Most pharma companies now understand that managed care organizations (MCOs) and pharmacy benefit managers (PBMs), in search of greater healthcare value, have changed the basis for how they make coverage decisions for new treatments. Under outcomes-based access (OBA), new treatments seeking to gain a high level of coverage must demonstrate compelling pharmacoeconomic value to receive preferred formulary inclusion or a robust position in a disease management program. 	

Since OBA became the decision making paradigm, it has driven the success (and failure) of many new drugs. It's not overstating matters to say that in most pharma companies OBA is driving decisions regarding product development, corporate development, marketing, and sales. But the biotech sector seems to still be lagging on this matter for a variety of reasons.	

In The Bruckner Group's 2003 study, payers consistently indicated that biologics are at the top of their lists for future cost-containment efforts. They see it as necessary because they experience a significant gap between biologics' costs-including acquisition, drug delivery, and additional medical testing-and the pharmacoeconomic value provided. AdvancePCS has publicly forecast that it is working to reduce biological expenditures by 30 percent.				

Perhaps payer attitudes toward biologics are best summarized by a pharmacy director from a leading MCO, who stated in the study: "I cannot continue to spend $3 million dollars to treat 150 patients, only to find the 30 patients that will get three months of relief and the 10 that end up with expensive liver problems. It just doesn't make sense." 	

Payers are extremely concerned with noncompliance and early treatment termination resulting from the difficult dosing schedules, side effects, and safety issues associated with many biologicals. For example, in a recent BGI Academic Collaboration Program study of more than 1,000 gastroenterologists (in collaboration with Sean Hurley, MD, and Eric Lawitz, MD, both of Brooke Army Medical Center, and presented at 2004 Digestive Disease Week), The Bruckner Group found that 12 percent of hepatitis C patients who initiated a biological drug therapy do not complete it. Payers experience heavy losses when patients who initiate high-cost therapy discontinue it early or skip doses. The cost is not only monetary, but, more important, there is a simultaneous drop in healthcare outcomes and overall treatment value.	

To improve biologicals' outcomes and value, companies need to provide additional support and educational initiatives, as well as side-effect management that will improve compliance and help patients complete therapy. A 2002 study at Northwestern University has shown an active intervention program for hepatitis C patients can decrease the treatment drop-out rate from 10 percent to 3 percent. Such programs create a clear path for companies to work with payers for mutual benefit, creating programs that solidify the biologicals' value proposition.	

Yet as matters stand, payers clearly believe that the high cost of biologics will most often exceed any direct monetary benefit gained from using them. This doesn't mean that payers will set aside cost considerations when assessing biological therapeutics. In fact, they do just the opposite. Payers are making aggressive choices, relying on evidence-based disease management and pharmacoeconomics to minimize their losses. For example, they continue to seek out evidence that the management of a chronic disease by a biologic will keep the disease in check, alleviating high medical and emergency costs.	

That approach leaves biotech companies facing the same issues as pharma-the need to produce sound, comparative value propositions for their products, backed by solid, rigorous proof. Biotech companies that fail to meet this standard are likely to encounter the same intense resistance and resulting revenue loss as Biogen did with its latest product, Amevive (alafacept).	

In 2003, Biogen introduced Amevive, the highly anticipated first biologic indicated for psoriasis. The product was poised to be a big hit with patients, physicians, and payers alike. Biogen, however, did not appropriately incorporate into Amevive's managed markets and pricing strategy the critical pharmaco-economic value arguments that are now at the heart of any substantive formulary submission dossier. 				

Biogen priced Amevive at a significant cost premium over Amgen's Enbrel (etanercept), the market leader with at least 75 percent share of the biological market for psoriasis. Biogen apparently assumed that Amevive could command a price premium for three main reasons: 	

It is the first biological with an FDA-approved indication for psoriasis. (Enbrel and other biological treatments are used off-label, although Enbrel was indicated for psoriasis in May 2004.)

Amevive uses a unique immunosuppressive method of action.

The product offers the possibility of a more durable response.

From payers' perspectives, however, Amevive's "value proposition" offers no meaningful pharmacoeconomic value over that of lower-priced competitors. Being the first biological for psoriasis, while a useful marketing message to garner grassroots support, is an attribute with no meaningful healthcare value. Although at the time, the other specialty pharma products for psoriasis were all being used off-label, such a designation was moot in the face of reported efficacy and physicians' successful experiences with those products. At Amevive's launch, Enbrel had already been treating rheumatoid arthritis patients for years and had been used by dermatologists for the treatment of psoriatic arthritis for more than a year. Doctors and payers were familiar with Enbrel and confident about its efficacy and safety.	

The introduction of a new method of action is only as valuable as the new approach's ability to address market needs by improving outcomes (increasing efficacy, increasing safety, and/or reducing side effects) or reducing costs. Unfortunately, most payers consider Amevive's efficacy as equivalent to Enbrel's, yet Amevive requires a 60â90 day onset of action period compared with Enbrel's 14â21 days. Furthermore, payers consider Amevive's durability of response to be rather anecdotal and want more data to demonstrate a clinical and pharmacoeconomic significance with meaningful impact on the healthcare value proposition.	

Amevive also comes with additional costs not encountered with Enbrel. Enbrel requires a subcutaneous self-injection at home; Amevive needs intravenous or intramuscular delivery by a doctor or nurse. Perhaps Biogen believed that administration would afford a Medicare advantage. But in reality, doctors must obtain the drug directly and have reason to fear that a shortfall or delays in reimbursement will cost them personally. Enbrel, meanwhile, is available at retail pharmacies at no risk to doctors. Amevive also requires regular monitoring of immune cell counts. In short, the therapy did not offer payers a meaningful value proposition.	

As a result, Amevive has failed to achieve widespread coverage on preferred formularies, and many doctors became concerned when coverage was denied even after Herculean efforts. Patients also balked at the often 20â30 percent co-pay required for Amevive. As a result, physicians and patients largely ignored Amevive, and it suffered an essentially stillborn launch. Post-launch results were further hindered by anecdotal reports suggesting that Amevive's real-world clinical efficacy was less than the company's claims. Even as Biogen diligently attempted to address many of the issues, Amevive's first quarter revenues in 2004 plunged to only $13 million, down from $17 million in the fourth quarter of 2003-a fraction of Biogen's expectations.	

More than a few Wall Street analysts believe that Amevive's poor launch-and the loss in projected revenue-drove Biogen's merger with Idec. As the theory goes, Biogen was compelled by the need to get a deal done with another company before its stock took a plunge, leaving Biogen as a wounded takeover candidate. This case study illustrates the very high price that biotech companies can pay for ignoring payer's OBA approach with its focus on healthcare value.	

Roche's combo therapy for hepatitis C shows how incorporating OBA principles can produce an unqualified success. Before launch, Roche assessed the clinical outcomes of Pegasys+Copegus (peginterferon alfa-2a/ribavirin) compared with the standard of care and market leader at the time, Schering-Plough's Peg-Intron+Rebetol (peginterferon alfa-2b/ribavirin). 				

Roche understood that in the current payer climate, Pegasys' similar outcomes to Peg-Intron would not justify a pricing premium and that nothing could be gained by trying to do so by chipping at the margins of the co-therapy's clinical success. Realizing that a pricing premium had no basis in the evidence, Roche went with the theory that, with all else being relatively equal, a lower price would likely win market share.	

At launch, Pegasys+Copegus was priced to offer similar patient outcomes at significantly better value than Peg-Intron+Rebetol. Coupled with an excellent, utilitarian, and focused strategy, Roche captured more than 40 percent share from Schering-Plough in just 12 months.	

The Bruckner Group's involvement in product developments and launches that successfully incorporate OBA strategies led it to develop a model and methodology that has been validated across therapeutic markets. The model consists of qualitative assessments, quantitative measurements and metrics, and a set of guidelines. Pharma and biotech companies can use the following principles from the model to successfully launch new products in an outcomes-driven world:				

 It's okay to have high expectations as long as they are tempered by the realities of how a product actually delivers value to a true market need. All too often expectations are based on a heightened sense of what one hopes rather than on the data. Responsible assessment of clinical results, technology limitations, and market needs is essential in dealing with the practical aspects of an increasingly managed markets-centric drug industry. A plan should be guided by the data and its analysis, and not the other way around.	

Creativity is good; evidence is better. But having both is the key.

 It is always tempting to try to leverage a snappy or compelling advertising message as the central focus of a marketing plan. Using the Amevive example, although being first to market with a specific indication might sound good, it is irrelevant if many players are already successful off-label alternatives. If you can't assign a dollar value or a direct clinical benefit to your message, neither can your customer.	

 It's important to pay attention to trends and market shifts in the company's customer base. For example, if payers are clearly assessing therapies with a specific value-based criteria, give them what they want to the best of the company's ability. With an explosion in the volume of sales detailing and ever-shrinking available time, physicians want useful, data-driven information, not flash. Make prescribing your product easy and anxiety-free.	

 Who are they now, and who will they be in the near future? Always compare your product, in both development and marketing, to your true competition. Companies gain nothing from "strategically" comparing their product to inferior ones that are otherwise irrelevant in practice. Expect independent comparisons among payers, physicians, patients, and competitors that will render yours utilitarian or obsolete. Providing utility leads to good will, enhanced reputation, and ultimately support.	

Create defensible value; price accordingly.

 Arriving at price has always been a painful process for the healthcare industry. Although it is still quite difficult, the concrete nature of pharmacoeconomics and activity-based costing provides a great deal of guidance for knowing what the current system will bear. The days of price premiums for quality of life or cosmetic advantages devoid of healthcare value are over. Prices should be set according to the overall cost burden a new therapy will place on the system, relative to the outcome it can deliver compared with competitors.	

Biologics are different from pharmaceuticals in many ways, but their differences are minimized when it comes to payer reimbursement and coverage decisions. Pharma companies are further along in the process of adapting to OBA because they have by necessity understood the market shift sooner.				

That affords biotech companies an advantage: They are in a position to learn from the mistakes some pharma companies made during the process of developing OBA strategies. Those mistakes, costing many millions of dollars, need not be repeated if biotech companies engage the process thoughtfully and, in particular, are attuned to the problems others have already experienced and solved.	

Biologics and specialty pharmaceuticals, which typically target small patient populations, have historically necessitated a high per-patient cost to justify their R&D investment and expensive manufacturing and packaging processes.

Pharmaceutical Executive-06-01-2004

June 2004 Table of Contents

Why Alliances Fail

Hire Expectations

DTC's Next Chapter

Biologics Beware