One of the biggest developments in the pharmaceutical industry in recent years has been the evolution and growth of markets outside of the US. In just the past six years, the revenue attributed to overseas markets has grown from 35% to 45% of total pharma industry revenues. With this growth has come the need for marketers to understand the top foreign markets with the same depth and clarity with which they understand the US market.
Many issues that were once only local to the US are now viewed broadly across the major markets throughout the world. To formulate their strategies and tactics, marketing teams must now answer a more complex set of questions: What is the future need for our product in various countries? What are the important clinical endpoints for our product on a global scale and within specific countries of interest? What segmentation strategies should we employ on a global level and within specific countries to optimize our targeting efforts? What strategies should we employ in various countries to maximize access to our product around the world? What should be the global positioning and messaging strategies? What country-specific refinements need to be incorporated? How is the product performing in each country, e.g., tracking, and what local-level adjustments need to be considered?
In order to support this increased need for information, savvy marketing research agencies have broadened their offerings to ensure that the quality of information for marketing decisions is consistently high across the world.
When product teams contemplate conducting marketing research in multiple countries, there are some key issues they should know before initiating the project. Even more critical, they should be confident that the marketing research agency or partner they choose to hire for each and every international project helps them refresh their knowledge about a number of key issues. This includes understanding:
■ Medical and reimbursement systems: Provides the context for understanding the level of access physicians and patients have to medications, as well as how much influence the system has on the choices made by prescribers
■ Treatment practices: Ensures that the right respondents are recruited in each region
■ How and at what pace the project-related logistics and tasks get accomplished in each country: Allows for the management of expectations for what can be collected in each country and within what time frame.
Just like well-prepared world travelers use guides that offer advice on what sites to visit, which hotels to consider and how to take advantage of the local cuisine, pharmaceutical marketing researchers need a master guide of practical tips for effectively executing insightful, yet inherently complicated, international studies.
The balance of this article shares some general knowledge, tips and “best practices” for global marketing research. Keep the list handy to remind yourself of its contents prior to every international study. We provide focus on the top nine countries in terms of pharmaceutical revenues: the United Kingdom, France, Germany, Italy, Spain, Japan, Mexico, US and Brazil.
United Kingdom
When conducting medical marketing research in the UK, it is important to account for how the National Health Service (NHS) greatly influences the system, resulting in a very cost-conscious environment.
Medical and Reimbursement System
■ The NHS (National Health Service) rules the day
• Most patients have government-sponsored insurance
• Being cost conscious dominates in a mostly public healthcare system
• Physicians do not have much choice in trying to use expensive medications when the NHS will not pay for them
• Generic alternatives are frequently used first line
■ A minority of patients have private insurance that gives them access to a greater number of medications
■ Direct-to-consumer promotion is prohibited
Treatment Practices
■ All specialist physicians working as part of the NHS are hospital-based
■ Internal Medicine physicians (IMs) do not exist
■ The dual Hematology/Oncology specialty does not exist
• Generally speaking, Oncologists treat solid tumors and Hematologists treat liquid tumors
• Clinical Oncology specialty combines radiation and medical oncology
■ Consultants and Specialist Registrars (SPRs) should be considered for interviews
• SPRs are “junior” physicians with less clinical experience, but still make decisions
• Consultants manage multiple SPRs
■ NICE (National Institutes for Clinical Excellence) guidelines greatly influence treatment decisions as they may influence funding decisions for medications
■ Physicians tend to be relatively conservative in their treatment strategies and slower to adopt new therapies
Logistical Tips
■ London is a “must” city, but regional guidelines for specialty areas, e.g., oncology, may necessitate the addition of other cities such as Birmingham and Manchester
■ Morning research is virtually impossible
• Research can be conducted Monday through Friday
• Workloads in the hospital allow for a few afternoon interviews, but evening time slots are preferable
• One-hour qualitative telephone interviews are possible
■ British English is not the same as US English
• English-version materials should be reviewed and adjusted accordingly to account for British terminology
France
Conducting medical marketing research in France is relatively easier than in other countries as participants are generally cooperative, physicians’ prescribing choices are less regulated and there are fewer limits placed on scheduling interviews.
Medical and Reimbursement System
■ Most patients have state health insurance
• Most drugs are included in the social security plan and reimbursed
■ Payers are difficult to interview and not worth the cost
• They refuse to answer a lot of questions due to confidentiality issues
• Interviewing Key Opinion Leaders (KOLs) about payer issues is often a better option
Treatment Practices
■ Regional hospitals tend to specialize in treatment areas, e.g., leukemia versus lymphoma
• Recruiting multiple physicians from the same hospital is necessary
• Budget issues vary dramatically from hospital to hospital
■ The dual Hematology/Oncology specialty does not exist
■ Sampling of drugs is illegal
Logistical Tips
■ Research locations to consider include Paris, Lyon and Marseille
■ There is a fair amount of flexibility for conducting research
• Morning, afternoon and evening interviews are possible
• On-time and show rates are very good
• 45- to 60-minute interviews are acceptable
• Scheduling up to eight studio interviews per day is possible
• Two to three focus groups per day is possible
■ Avoidance of mixing specialties in focus groups is of even greater importance in France than in other countries
■ Telephone-depth interviews are becoming more popular
■ Average age of physicians is about 50 years old, so allow for at least 30 years in practice for screeners
■ Physicians generally have a distaste for projective techniques and “emotional response” methodologies
■ Patient research can be interesting, but of minimal value because they generally indicate that physicians entirely influence the final decisions
Germany
Germany, it is important to remember that physicians are held accountable for their own budgets, which clearly affects their decision making. When conducting research in this country, Wednesday is the most productive day of the week.
Medical and Reimbursement System
■ Budget issues are critical among physicians
• Healthcare system is mostly public
• Monthly cost for prescription drugs per patient is assigned to physicians by the federal statutory health insurance or accredited association
• If over budget, physicians need to defend themselves and be held accountable
• Specialists generally get a larger budget than General Practitioners
■ Hospitals are increasingly being funded based on Diagnostic Related Groups (DRGs)
• This system results in partial restrictions on products and earlier hospital discharges
■ Direct-to-consumer promotion is prohibited
Treatment Practices
■ Regional differences can be important due to local protocol, especially in specialized treatment areas, e.g., HIV, oncology, hepatitis
■ Many specialists are both hospital-based and office-based, e.g., Oncologists, Hematologists, Urologists, Gastroenterologists, etc.
■ Internal Medicine physicians (IMs) exist and are hospital-based specialists
■ Hematologist/Oncologist is one dual specialty
• No separate specialties for hematology and oncology
Logistical Tips
■ Research locations to consider include Berlin, Munich, Hamburg and Frankfurt
■ Wednesdays are desirable for research due to availability
• Wednesdays are reserved for research/administration or “days off”
• Scheduling research on Monday and Friday can be difficult
• Morning interviews are very difficult (start at noon)
• German physicians are punctual, and on-time and show rates are excellent
• 45- to 60-minute interviews are acceptable
• Six to eight studio interviews per day is possible
• Summer research is easier than in other EU countries
■ Physicians generally have a distaste for projective techniques and “emotional response” methodologies
• Responses tend to be literal
■ Recruiting pharmacists is increasingly difficult as pharmacies become more centralized
• Fewer pharmacists
■ Patient empowerment is leading to increased research among consumers, but keeping the interview length short (20 to 25 minutes) is important
Italy
In Italy, citizens generally have open access to services and pharmaceuticals, but it is important to note that numerous regions, as well as different hospitals within them, create their own formulary.
Medical and Reimbursement System
■ Public access to healthcare is granted to every citizen
• Most hospitals are public and open to everyone, with most services free or for a small fee
• The wait for public services can be long and patients can pay for faster service, but it is expensive
• Private insurance is becoming more popular
■ General Practitioners (GPs) are warned by local healthcare authorities when they prescribe too many expensive agents
• Physicians not held to a budget, but the government is expected to employ budgets
■ The European Medicines Agency (EMEA) approves new drugs for use in Italy
• 20 regions create their own formulary and each hospital in each region creates its own formulary
■ Prescription drugs are divided into many classes for reimbursement purposes when obtained at retail pharmacies
• Class A—fully reimbursed
• Class C—out-of-pocket
Treatment Practices
■ Regional differences can be important, especially in specialized treatment areas
■ Specialists are typically hospital employees
• Most have a public and private practice
■ Oncologists treat solid tumors and Hematologists treat liquid tumors
Logistical Tips
■ Research locations to consider include Rome, Milan and Naples
■ In-person interviews are much preferred over telephone interviews
• Scheduling up to eight studio interviews per day is possible
• Morning interviews are very difficult (start at 1 p.m.) as are Fridays
• 60-minute in-person interviews are acceptable, but telephone interviews should not exceed 15 minutes
• Internet surveys can take one to two weeks longer to field than in other countries
• Physicians are routinely late, but do not mind waiting if asked
■ Research participants tend to skew responses toward the higher end of scales as they do not want to appear negative
Spain
In Spain, behavioral and cultural differences by region are important to consider, motivating researchers to ensure sample coverage in Madrid and Barcelona at a minimum.
Medical and Reimbursement System
■ Most patients have state health insurance
■ The central government approves the commercialization of pharmaceuticals, but regional governments can apply their own restrictions
• Pricing and reimbursement strategies are decided on a national level, and Key Opinion Leaders (KOLs) are consulted
• Clinical guidelines are important for reimbursement purposes
■ Hospital pharmacists assume the role of gatekeepers for access to drugs
■ Primary Care Physicians (PCPs) get economic bonuses if at least a minimum proportion of their prescriptions are for generic agents
Treatment Practices
■ Regional differences are important in highly specialized treatment areas, e.g., acute leukemia, HIV
■ Most physicians are both office-based and hospital-based
• Many work in the hospital in the morning and in a private practice in the afternoon
■ Internal Medicine physicians (IMs) do exist, but they tend to specialize in an area such as infectious disease, HIV, emergency care and intensive care
■ Emergency room physicians do not exist as a specialty
■ Hematologist/Oncologists exist
• Hematologists treat liquid and solid tumors
• Oncologists treat only solid tumors
Logistical Tips
■ Research participants take their time to commit—filling the schedule can take up to the day of research
• Scheduling up to eight studio interviews per day is possible
• Morning interviews are virtually impossible (start at 1 p.m.)
• Scheduling research on Fridays can be difficult
• 45- to 60-minute in-person interviews are acceptable, but telephone interviews should not exceed 20 minutes
• Internet surveys can take one to two weeks longer to field than in other countries
■ Conducting research among seriously ill patients is considered unethical
■ Privacy issues with patients can be a serious issue, e.g., HIV patients typically ensure they are not being videotaped
Japan
One can conduct excellent research in Japan and obtain extremely insightful results, but you must adapt your expectations about costs and timing. Research typically requires twice the time and money than any other country.
Medical and Reimbursement System
■ One national health insurance system where patients pay 30 percent of the total cost up to a maximum amount per year and then are fully covered
• Those with severe chronic conditions or elderly are fully reimbursed
■ A small amount of treatments are not reimbursed—“lifestyle treatments,” e.g., cosmetics, plastic surgeries, erectile dysfunction treatments, smoking cessation
■ Hospital/clinics dispense prescription drugs either directly or through dispensing pharmacies as part of their infrastructure
■ Off-label prescribing is much less common than in other countries
Treatment Practices
■ Two general treatment settings—hospitals (20-plus beds) and clinics (0-19 beds)
■ Patients can choose their own doctor and treatment setting without cost differences
■ Patients go to small clinics for relatively mild and short-term conditions and go to large hospitals for more severe diseases
■ Generics are not widely acceptable—first, there are not enough incentives for generic prescribing, and second, questions of quality linger
■ All physicians are trained to be “specialists”—there are Internal Medicine physicians (considered specialists), but no General Practitioners
■ Cancer is generally treated by the “body part” specialist, e.g. Gastroenterologists treat stomach cancer, Urologists treat prostate cancer, Breast Surgeons treat breast cancer
Logistical Tips
■ Doctors are considered key authority figures and addressed with reverence, on par with lawyers and politicians—as a result, it is often difficult for moderators to probe or challenge respondents on their ideas, and answers must often be obtained through indirect questioning
■ Acceptable times for conducting in-studio interviews with physicians is limited to weekday evenings and occasionally Saturdays
■ For quantitative research with physicians, the best approach is to have local field interviewers visit physician offices and fill out the questionnaire on paper
■ A typical 45-minute interview will take 60 to 75 minutes in Japan
■ Focus group sizes are generally small—typically made up of six respondents who are similar demographically, e.g., ages, position, etc.
■ Phone interviews must be short (five minutes or less) since it is culturally more appropriate to talk in person
■ Videotaping respondents typically does not happen because of privacy laws
Mexico
Medical marketing research is not conducted as often in Mexico as it is elsewhere, but a recent increase in requests to consider it for a greater number of research studies suggests that could change.
Medical and Reimbursement System
■ There are two main healthcare systems:
• IMSS (Instituto Mexicano del Seguro Social)—attends to private company workers
• ISSSTE (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado)—attends to government workers
• Drugs are generally dispensed to those patients at no cost (some hospitals require a minimum payment)
■ Private patients (non-IMSS and non-ISSSTE) pay out-of-pocket for their medications, and deductibles can be more expensive than the cost of the medication
■ To sell more medications, pharmacies may not ask to see an actual prescription when dispensing, but they do require seeing prescriptions for restricted drugs, e.g., opioids
Logistical Tips
■ Extra personal attention is required during recruiting efforts, e.g., recruiters need to treat physicians as very important people
■ Over-recruiting is necessary as physicians often cancel at the last minute
■ Physicians tend to require more time to complete surveys and interviews than in other countries
• A 45-minute survey may take 55 to 60 minutes
• Morning interviews are possible
• Recruiting/scheduling up to eight respondents in one day is possible
• Physicians are slowly adopting the practice of completing Internet surveys; they would rather speak to a moderator than sit in front of a computer
■ Asking income questions is unacceptable
• Surrogate questions are asked, e.g., type of car owned, number of rooms in house, level of education for the head of the household
■ Physicians tend to skew their ratings toward the higher end of the scale, e.g., they are very receptive to new products
Brazil
In Brazil, although participants are slower than their counterparts in other countries to adopt the practice of completing Internet-based surveys, they are still very willing and eager to take part in studies.
Medical and Reimbursement System
■ The Agencia Nacional de Vigilancia Sanitaria (ANVISA) is the governing body for pharmaceuticals
■ There is no reimbursement for medication
• Patients do not require a prescription, except for a few “controlled” medications
Treatment Practices
■ Physicians frequently work across multiple settings, e.g., hospitals, clinics, offices
■ Many physicians prescribe “compounding” medications and refer to them as “formula”
• Cheaper than generics and therefore more affordable
• Problem: Patients do not know if the dosage of the medication is exactly as it is supposed to be
Logistical Tips
■ Physicians are open and willing to participate in marketing research
• Respondents accept and answer all types of questions
• Recruiting/interviewing up to eight studio interviews per day is possible
• Early morning research is possible
• Friday research is very difficult
• July and December are difficult months for research
• Physicians are very slowly adopting the practice of completing surveys on the Internet, thus in-office interviews are done for quantitative surveys
■ Asking income questions is unacceptable
• Surrogate questions are asked in order to approximate respondent’s income, e.g., number of bathrooms in house, types of appliances, level of education for the head of the household, whether they employ a maid, type of car owned, etc.
United States
By way of comparison, the United States is arguably the easiest country in the world to conduct pharmaceutical marketing research. The culture is very conducive for all kinds of qualitative and quantitative studies. As such, when conducting primary research in multiple countries where you include the US, it is important to remember to manage (not lower) expectations for the other countries where timelines are longer.
Logistical Tips
■ Money can solve a host of problems, including recruiting issues and tight timelines
■ Many good facilities exist in most markets across the country (convenient, experienced recruiters and facility managers, very customer-focused)
■ Facilities are state-of-the-art and comfortable (excellent Internet access)
■ Research is conducted faster and with more flexibility than in other countries
• All data collection methods acceptable, e.g., in-person, in-office, phone, Internet, etc.
• Easier to recruit all types of physicians (Generalists, Specialists, Key Opinion Leaders)
■ The greatest risk is over-researching a finite population
• Beware of recruiting “professional” respondents time after time, especially in the top markets
■ Beware of regional differences
• Some markets are much more concerned about cost as a result of different levels of managed care influence
• Some markets can be more “academic” or more “aggressive” than are others
Conclusion
As primary marketing research professionals continue to span the globe conducting and managing international studies, living with the “When in Rome…” philosophy in mind will greatly increase the probability that the research will be successful. To effectively manage expectations among everyone, including senior management, research professionals should spend time before each international project reminding themselves of the local medical systems, treatment practices, and how and at what pace things get accomplished in the particular countries of interest.
It is critical to be flexible, listen to the locals and build partnerships. Additionally, while the technology exists to observe research in most countries via videoconferencing, there is no substitute for physically being there to observe and develop a rich understanding of the research results.
Bart Weiner is president of GfK V2 and Brian Hull is president of GfK Strategic Marketing. Both companies are pharmaceutical marketing research and consulting firms and part of the GfK US Healthcare Companies.
From the June 01, 2007 Issue of MM+M - Medical Marketing and Media
