Market Penetration: What 60 Sales Managers Can Accomplish

[mnholdem]

What can Mike Castagna and his Afrezza sales team accomplish in 2016?

Market Penetration 2016 Worksheet - Afrezza

Providers – visits in 2016 to endocrinologists and similar high-prescribing physicians to detail Afrezza.

1. 60 Territorial/Regional Sales Managers (100% focus on detailing of Afrezza)
2. 500 visits/week (1-2 per day x 5 days x 60 Sales Mgrs)
3. 9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)

   * NOTE: 2 weeks dropped for holidays/vacations

Patients with Diabetes (PWD) - visits to physicians detailed in 2016 by Afrezza Sales Mgrs

1. 9,000 physicians detailed on Afrezza by end of CY-2016 (see Providers)
2. 450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)

Results – Weekly TRx* for Afrezza by EOY 2016

1. Afrezza market = potential patient awareness by EOY 2016 = 450,000 PWD per week (see Patient with Diabetes)
2.   1% patient penetration =   4,500 Afrezza TRx per week
3.   5% patient penetration = 22,500 Afrezza TRx per week
4. 10% patient penetration = 45,000 Afrezza TRx per week

 

* Total U.S. prandial market (all brands) = 300,000 TRx per week reported by IMS (2015) + 100,000-150,000 unreported TRx per week

Results – Weekly TRx for Afrezza by EOY 2017

1. Stay tuned...

---

National Center for Health Statistics

Source: www.cdc.gov/nchs/fastats/diabetes.htm

Data are for the U.S.

Morbidity

• Percent of adults 20 years and older with diabetes (physician-diagnosed or undiagnosed): 12.6% (2011-2014)
• Percent of adults 20 years and older with physician-diagnosed diabetes: 9.6% (2011-2014)
• Percent of adults 20 years and older with undiagnosed diabetes: 3.0% (2011-2014)

Source: www.cdc.gov/nchs/data/hus/hus15.pdf#040

Ambulatory care visits

• Number of visits (to physician offices, hospital outpatient and emergency departments) with diabetes as primary diagnosis: 37.3 million

Source: www.cdc.gov/nchs/data/ahcd/combined_tables/AMC_2009-2010_combined_web_table01.pdf

Hospital inpatient care

• Number of discharges with diabetes as first-listed diagnosis: 635,000
• Average length of stay: 4.6 days

Source:  www.cdc.gov/nchs/data/nhds/2average/2010ave2_firstlist.pdf#x2013

Mortality

• Number of deaths: 75,578
• Deaths per 100,000 population: 23.9
• Cause of death rank: 7

Source: www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf

---

These statistics demonstrate that our current healthcare environment in the U.S. for the treatment of diabetes is inadequate. It's time for a paradigm change. It's time for Afrezza.

[peppy]

from the CC transcript
Now, I want to bridge into a question that we often get which is around our target market and how are we going to go about the segmentation of the current field footprint. Our focus is on the 6.5 million patients with diabetes, who are on basal plus or minus insulin, the majority of whom these patients are not at goal.

So if you look on the left side of this chart, Type 1 diabetics are approximately 1.25 million, Type 2 basal who are not on Bolus is roughly 2.75 million and Type 2 basal Bolus patients who are on basal Bolus regimen is almost 3 million. This is how you get to the 6.5 million patients with diabetes.

Of these, you would see monthly prescription trend of approximately 1.7 million prescriptions in a given month and targeting this population. Our current field footprint is about 1.4 million of those prescriptions. We’re targeting about 75% of the insulin market with our current sales structure.

The next question I often get that I think is important for everyone is around our price point and the cost of Afrezza. Afrezza, as you know, is reimbursed across all payor segments from commercial to Medicare, but the rapid-acting analog price increases over the last three years has really started to create challenges in the marketplace.

You see in the box below the WAC price of rapid-acting analog has increased 80% since July 2013. So today, when you look at the price of Afrezza since we got approved, the price of Afrezza is cheaper to insulin as we now know the average price of insulin per day is approximately $19 and if you look at the recent launch of our titration pack, we’ve priced it at $3 a unit or cartridge and so when you look at $3 a cartridge and a patient was to take three cartridges a day, you could be looking at a price point of $9 a day.
If they were to take six cartridges either because they need additional dosing or follow up dosing, you’ll be looking at a price point of $18 a day. So the current WAC price of Afrezza is not the challenge. The challenge is payors are trying to control their cost and so they’re being more restricted on formularies and that’s often why we’re seeing patients may need to switch between a Humalog and NovoLog that they’re trying to manage the cost trends especially in this category.

[peppy]

The next question we get is around our branding campaign. It’s important to know that MannKind was able to develop and launch a new brand campaign and move away from the Sanofi’s surprise of insulin. We’re proud to announce that our focus is not on the inhalation aspects of Afrezza, but it’s much more on the insulin and outsulin component.

And so you see here just a brief snapshot of what that would look like and how we talk about insulin is how quickly it acts and we talk about – how quickly it disappears. We really want to spark a dialogue in the marketplace around the insulin and outsulin components of insulin and how Afrezza plays a new role within the treatment of these patients, highlighting the PK profile as we see it today. There is obviously a lot more behind the campaign, but I want you to be rest assured the feedback from patients and physicians has been extremely positive.

www.mannkindcorp.com/Collateral/Documents/English-US/Baughman%20poster%20100-LB%20FINAL%20X2.pdf

And so there was a lot of confusion when we looked back at the data and the market research. And this new titration box literally will simplify the process for the doctor, the patient and the pharmacy by allowing them to have a 30-day supply of titration of 180 cartridges which will provide them enough units to combine to get the 4, 8, 12 or 24 units in a dose to ensure they have an optimal experience and don’t run short within a given month.

titration pack has an sku

mnkd.proboards.com/thread/5910/mannkind-afrezza-sku-ndc-numbers

[Deleted]

Aug 10, 2016 7:59:34 GMT -5 mnholdem said:

Market Penetration 2016 Worksheet - Afrezza

Providers – visits in 2016 to endocrinologists and similar high-prescribing physicians to detail Afrezza.

1. 60 Territorial/Regional Sales Managers (100% focus on detailing of Afrezza)
2. 500 visits/week (1-2 per day x 5 days x 60 Sales Mgrs)
3. 9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)

   * NOTE: 2 weeks dropped for holidays/vacations

Patients with Diabetes (PWD) - visits to physicians detailed in 2016 by Afrezza Sales Mgrs

1. 9,000 physicians detailed on Afrezza by end of CY-2016 (see Providers)
2. 450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)

                                                                                                                                                                                                                                                                                                                                                        

Corrections:

500 visits/week (1-2 per day x 5 days x 60 Sales Mgrs)

9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)

The 500 physicians ( high prescribers - possibly part of the 3000 who had written atleast 1 rx ) will be visited over and over again.
in your scenario - every one looks like touch and go which should not be the case.

1 doc can be visited once every week of the month atleast for 3 months , before reducing the frequency.

450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)

Based on my correction factor, this math needs to be changed.
further all the 10 patients are not target and what would prompt the doc to bring up Afrezza? ( compliance, needle phobia,a1c > 7 very subjective as some docs are ok with as much as 9? )

[peppy]

Aug 10, 2016 10:27:46 GMT -5 @iam2sekc4u2002 said:

Aug 10, 2016 7:59:34 GMT -5 mnholdem said:

Market Penetration 2016 Worksheet - Afrezza

Providers – visits in 2016 to endocrinologists and similar high-prescribing physicians to detail Afrezza.

1. 60 Territorial/Regional Sales Managers (100% focus on detailing of Afrezza)
2. 500 visits/week (1-2 per day x 5 days x 60 Sales Mgrs)
3. 9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)

   * NOTE: 2 weeks dropped for holidays/vacations

Patients with Diabetes (PWD) - visits to physicians detailed in 2016 by Afrezza Sales Mgrs

1. 9,000 physicians detailed on Afrezza by end of CY-2016 (see Providers)
2. 450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)

                                                                                                                                                                                                                                                                                                                                                        

Corrections:

500 visits/week (1-2 per day x 5 days x 60 Sales Mgrs)

9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)

The 500 physicians ( high prescribers - possibly part of the 3000 who had written atleast 1 rx ) will be visited over and over again.
in your scenario - every one looks like touch and go which should not be the case.

1 doc can be visited once every week of the month atleast for 3 months , before reducing the frequency.

450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)

Based on my correction factor, this math needs to be changed.
further all the 10 patients are not target and what would prompt the doc to bring up Afrezza? ( compliance, needle phobia,a1c > 7 very subjective as some docs are ok with as much as 9? )

[peppy]

And then we have identified several direct mail opportunities that we compile and see targeting patients directly in the mail. As you know, the average age of a Type 2 or Type 1 patient could be in the 45 to 55 range and sometimes direct mails are better way to go as opposed to digital for younger audience.

 Either way, we will have lots of data coming out in Q3 that would continue to fine tune our direct to patient efforts.

So we have several initiatives on track to launch starting in September which will be our first consumer print ad you will start to see out there in mid to late September pop up in some journals.

[peppy]

Aug 10, 2016 9:50:51 GMT -5 @kastanes said:

Great analysis of future prescriptions. With 1% penetration, should we begin to see 50 NRx added each week?

additionally Mike C said at the CC

We just launched our sample program two weeks ago and in the first two weeks we had well over 300 sample requests amongst our targets. Those just shipped literally late last week or early this week, people will be receiving them and so all the prescription trends that we’ve seen over the last few weeks have been without samples in the marketplace for a large majority of our customers.

Now that they have samples we know several doctors have said I want samples and copays in my office, once I have them I’ll start to prescribe further again. So those products are – both of those are starting to hit doctors’ offices this week and next week as well as last week.

add 300 as those will go out as RX

as near as I can tell those should be titration packs

[compound26]

Aug 10, 2016 10:27:46 GMT -5 @iam2sekc4u2002 said:

Aug 10, 2016 7:59:34 GMT -5 mnholdem said:

Market Penetration 2016 Worksheet - Afrezza

Providers – visits in 2016 to endocrinologists and similar high-prescribing physicians to detail Afrezza.

1. 60 Territorial/Regional Sales Managers (100% focus on detailing of Afrezza)
2. 500 visits/week (1-2 per day x 5 days x 60 Sales Mgrs)
3. 9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)

   * NOTE: 2 weeks dropped for holidays/vacations

Patients with Diabetes (PWD) - visits to physicians detailed in 2016 by Afrezza Sales Mgrs

1. 9,000 physicians detailed on Afrezza by end of CY-2016 (see Providers)
2. 450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)

                                                                                                                                                                                                                                                                                                                                                        

Corrections:

500 visits/week (1-2 per day x 5 days x 60 Sales Mgrs)

9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)

The 500 physicians ( high prescribers - possibly part of the 3000 who had written atleast 1 rx ) will be visited over and over again.
in your scenario - every one looks like touch and go which should not be the case.

1 doc can be visited once every week of the month atleast for 3 months , before reducing the frequency.

450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)

Based on my correction factor, this math needs to be changed.
further all the 10 patients are not target and what would prompt the doc to bring up Afrezza? ( compliance, needle phobia,a1c > 7 very subjective as some docs are ok with as much as 9? )

A few points for discussion:

"9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)"

In the annual shareholder meeting, Mike C. has clearly stated that their target is around 7,000 physicians initially, with endos mostly the focus right now. They will expand to PCPs only after they have penetrated the endos market. So, most likely, we will unlikely to hit 9,000 doctors in 2016. 

"The 500 physicians ( high prescribers - possibly part of the 3000 who had written atleast 1 rx ) will be visited over and over again."

Agree. Not sure where you get the 500 number (I do not have the impression of seeing this number mentioned by Mannkind anywhere), the actual top prescriber group might be even smaller (i.e., could be 200-300 physicians). But 500 sounds right to me. In the second quarter CC, after only 3-4 weeks of relaunch, Mike is saying that some of the doctors will be having 2nd and 3rd visits from Mannkind representatives at this point of time. 

"450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)"

We need to change that 9,000 to 7,000, that will result in 350,000 (rather than 450,000) PWDs per week. Plus, after a few weeks, a higher percentage of the visitors will be repeat visitors as time goes by (i.e., not all the visitors will be new patients). Additionally, some of the visitors may already have Afrezza prescriptions and some of them may not get a insulin prescription at all for a particular visit. 

[mnholdem]

Aug 10, 2016 10:27:46 GMT -5 @iam2sekc4u2002 said:

Aug 10, 2016 7:59:34 GMT -5 mnholdem said:

Market Penetration 2016 Worksheet - Afrezza

Providers – visits in 2016 to endocrinologists and similar high-prescribing physicians to detail Afrezza.

1. 60 Territorial/Regional Sales Managers (100% focus on detailing of Afrezza)
2. 500 visits/week (1-2 per day x 5 days x 60 Sales Mgrs)
3. 9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)

   * NOTE: 2 weeks dropped for holidays/vacations

Patients with Diabetes (PWD) - visits to physicians detailed in 2016 by Afrezza Sales Mgrs

1. 9,000 physicians detailed on Afrezza by end of CY-2016 (see Providers)
2. 450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)

                                                                                                                     

Corrections:

500 visits/week (1-2 per day x 5 days x 60 Sales Mgrs)

9,000 endos and h/p physicians detailed in 2016 (500 visits x 18 weeks*)

The 500 physicians ( high prescribers - possibly part of the 3000 who had written atleast 1 rx ) will be visited over and over again.
in your scenario - every one looks like touch and go which should not be the case.

1 doc can be visited once every week of the month atleast for 3 months , before reducing the frequency.

450,000 PWD per week will be visiting Afrezza-detailed physicians by EOY-2016 (9,000 docs x 10 patients/day average x 5 days/week)

Based on my correction factor, this math needs to be changed.
further all the 10 patients are not target and what would prompt the doc to bring up Afrezza? ( compliance, needle phobia,a1c > 7 very subjective as some docs are ok with as much as 9? )

I don't know of any pharmaceutical reps who would visit the same doctor every week.  The worksheet is considering only NEW visits. Certainly, the Afrezza Sales Manager may begin revisiting physicians after a period of time and that's why my analysis has only 1-2 visits per day.  I consider those to be NEW visits in addition to stopping by to see established accounts. My sales reps typically will make 4-6 visits every day in a highly populated territory.

Another factor that I did not include is the fact that one visit can be used to detail multiple doctors.  Take the case of the Dr. Combs that sportsrancho has posted about. He is scheduling a diabetes conference for his group's physicians and he may be inviting many regional physicians as well that are not affiliate with his group. But let's assume that Combs schedules a speaker to come and detail just the Rancho Family Medical group on Afrezza. This medical group consists of the following physicians:

Single Oak Office - Temecula
• Dr. Cristina Bailey
• Dr. Walter Combs
• Dr. Tae Im

Makena - Temecula
• Dr. Maisar Rahman
• Dr. Charles Taft

Temecula Parkway Office - Temecula
• Daniel Nunez, PA-C

Menifee Office
• Dr. Daniel Camarillo
• Dr. Rolando Gutierrez
• Dr. Eric Madrid
• Dr. Michelle Uttaburanont

Fallbrook Office
• Dr. Brandon Miller
• Dr. Georgiana Miller

Murrieta Office
• Dr. Charles Fraley
• Dr. Anna Julien

So, in this scenario of one small city/town in Southern California midway between Los Angeles and San Diego, all of these physicians (and possibly more) would be detailed in a single visit by an Afrezza Territorial or Regional Sales Manager.  The Market Penetration Worksheet doesn't take multiple physicians per visit into account. Nor does it add additional Afrezza Sales Managers, which one could reasonably assume would be hired by MannKind when Afrezza sales generate sufficient growth to justify new hires.

This is just a simple calculation of 60 Sales Mgrs making 1-2 NEW visits five days per week to determine a feasible number of visits each week to detail physicians for the first time. I would also expect that the approximately 5,000 endocrinologists and diabetologists being initially targeted, will be visited at least twice before year end and that the sales force will have moved onto detailing other HCP's by then.  I think that MannKind's thinking is that many of the Primary Care Physicians would be sending a PWD to an endocrinologist initially.  However, after becoming familiar with the simplicity of Afrezza and learning the patient titration protocols, many PCPs will elect not to send a PWD to the endo in every instance.

You are free to throw in additional factors to modify the workbook to what you think the numbers ought to be. I only go by what I, myself, would expect. If one of my sales reps didn't make at least five new prospect visits each week (not including Trade Shows), I would be calling him/her into my office to explain.  Coasting on past accounts is simply not tolerated in my family of companies...

Good fortune to you.

[Deleted]

Aug 10, 2016 11:07:22 GMT -5 mnholdem said:

Aug 10, 2016 10:27:46 GMT -5 @iam2sekc4u2002 said:

I don't know of any pharmaceutical reps who would visit the same doctor every week.  The worksheet is considering only NEW visits. Certainly, the Afrezza Sales Manager may begin revisiting physicians after a period of time and that's why my analysis has only 1-2 visits per day.  I consider those to be NEW visits in addition to stopping by to see established accounts. My sales reps typically will make 4-6 visits every day in a highly populated territory.

Another factor that I did not include is the fact that one visit can be used to detail multiple doctors.  Take the case of the Dr. Combs that sportsrancho has posted about. He is scheduling a diabetes conference for his group's physicians and he may be inviting many regional physicians as well that are not affiliate with his group. But let's assume that Combs schedules a speaker to come and detail just the Rancho Family Medical group on Afrezza. This medical group consists of the following physicians:

Single Oak Office - Temecula
• Dr. Cristina Bailey
• Dr. Walter Combs
• Dr. Tae Im

Makena - Temecula
• Dr. Maisar Rahman
• Dr. Charles Taft

Temecula Parkway Office - Temecula
• Daniel Nunez, PA-C

Menifee Office
• Dr. Daniel Camarillo
• Dr. Rolando Gutierrez
• Dr. Eric Madrid
• Dr. Michelle Uttaburanont

Fallbrook Office
• Dr. Brandon Miller
• Dr. Georgiana Miller

Murrieta Office
• Dr. Charles Fraley
• Dr. Anna Julien

So all of these physicians (and possibly more) would be detailed in a single visit.  The Market Penetration Worksheet doesn't take multiple physicians per visit into account. Nor does it add additional Afrezza Sales Managers, which one could reasonably assume would be hired by MannKind when Afrezza sales generate sufficient growth to justify new hires.

This is just a simple calculation of 60 Sales Mgrs making 1-2 NEW visits five days per week to determine a feasible number of visits each week to detail physicians for the first time.

You are free to throw in additional factors to modify the workbook to what you think the numbers ought to be. I only go by what I, myself, would expect. If one of my sales reps didn't make at least five new prospect visits each week (not including Trade Shows), I would be calling him/her into my office to explain.  Coasting on past accounts is simply not tolerated in my family of companies...

Good fortune to you.

I can confirm , one of the doc in my area  is met by Rep every week since they started. You can no way build a sales relationship by just visiting once. thats what SNY did... there is constant feedback and hand holding that plays an important role.
once sales reach a comfortable level,  foot print will be expanded.

u r talking about additional reps when is pure speculation and may be once sales improve.

Not all those multi physician group doctors see all 10 diabetic patients..not 100% of the daily patients are diabetic.

[mnholdem]

So cut the numbers in half if you like. I think they are realistic. I also didn't add too many variables because the 1%, 5% and 10% serve the purpose of eliminating 99%, 95% and 90% of patients, respectively, for the reasons that you and others may describe.

The worksheet is not intended to be sophisticated. I have other tools for that. I started the OP to simply convey what is possible to accomplish with 60 Afrezza sales managers. Knowing that there aren't 9,000 endocrinologists in the U.S. should, I think, cause the reader to realize that the worksheet imples the sales force will be detailing other physicians.

[kball]

Aug 10, 2016 10:37:35 GMT -5 peppy said:

And then we have identified several direct mail opportunities that we compile and see targeting patients directly in the mail. As you know, the average age of a Type 2 or Type 1 patient could be in the 45 to 55 range and sometimes direct mails are better way to go as opposed to digital for younger audience.

 Either way, we will have lots of data coming out in Q3 that would continue to fine tune our direct to patient efforts.

That could work.
Devil's advocate though i get a bunch of chipolte direct mail and i'm not eating their food no matter what the offer thank you very much.
Whether thats perception or still might be an ongoing problem just throwing it out as an example our company may face

[peppy]

And the next metric that we look at is around new writers and trialist. And in that number, we’ve seen almost 300 new prescribers in Q2 alone who [now bring] Afrezza in 2016, commemorate Afrezza for the first time. So we are seeing broad trialist happen and we know we’ll continue to cultivate that as we go into Q3 going forward.

[mnholdem]

Aug 10, 2016 11:17:38 GMT -5 @iam2sekc4u2002 said:

Aug 10, 2016 11:07:22 GMT -5 mnholdem said:

I don't know of any pharmaceutical reps who would visit the same doctor every week.  The worksheet is considering only NEW visits. Certainly, the Afrezza Sales Manager may begin revisiting physicians after a period of time and that's why my analysis has only 1-2 visits per day.  I consider those to be NEW visits in addition to stopping by to see established accounts. My sales reps typically will make 4-6 visits every day in a highly populated territory.

[clipped]

I can confirm , one of the doc in my area  is met by Rep every week since they started. You can no way build a sales relationship by just visiting once. thats what SNY did... there is constant feedback and hand holding that plays an important role.
once sales reach a comfortable level,  foot print will be expanded.

u r talking about additional reps when is pure speculation and may be once sales improve.

Not all those multi physician group doctors see all 10 diabetic patients..not 100% of the daily patients are diabetic.

Are the reps visiting every week for the same drug or does the sales visit more frequently because the pharmaceutical company the rep is working for has many, many drugs to discuss?  Afrezza reps only have one product to sell.

[Deleted]

Aug 10, 2016 11:41:16 GMT -5 mnholdem said:

Aug 10, 2016 11:17:38 GMT -5 @iam2sekc4u2002 said:

I can confirm , one of the doc in my area  is met by Rep every week since they started. You can no way build a sales relationship by just visiting once. thats what SNY did... there is constant feedback and hand holding that plays an important role.
once sales reach a comfortable level,  foot print will be expanded.

u r talking about additional reps when is pure speculation and may be once sales improve.

Not all those multi physician group doctors see all 10 diabetic patients..not 100% of the daily patients are diabetic.

Are the reps visiting every week for the same drug or does the sales visit more frequently because the pharmaceutical company the rep is working for has many, many drugs to discuss?  Afrezza reps only have one product to sell.

i can read your sarcasm, but arent we talking about Mannkind and Afrezza?