ALL ETHICAL PHARMACEUTICALS - MARKET OVERVIEW OF CONTRACT RESEARCH ORGANIZATIONS (CROs)

Kenneth A. Getz, President and CEO CenterWatch, Inc. Introduction The market for contract research organization (CRO) services has grown rapidly since the early 1990s. Worldwide, an estimated $6 billion in drug development dollars was outsourced to CROs in 2001; up from $3 billion spent in 1997. Overall industry revenue has been growing at a rate of more than 20% annually for more than seven years. There are signs that the rate of spending on drug development outsourcing services in the US has peaked. Large, publicly-traded CROs have reported annual net revenue growth of as high as 45% with 8% to 10% average operating margins. Top public CROs (e.g., Quintiles, Covance and Parexel) now generate revenue often exceeding that of their clients. In order to sustain high growth levels on a large revenue base, several top CRO companies have rapidly diversified into non-traditional services including drug discovery, electronic medical information and pharmaceutical sales and marketing. Quintiles is perhaps the strongest example of a company that has aggressively diversified its service portfolio moving into contract sales and informatics through its acquisitions of Innovex and Envoy. The CRO market is extremely volatile. The industry is consolidating rapidly the six major publicly-traded CROs steal an estimated 4% market share each year from established CRO players. Indeed, the failed merger attempt of Covance and Parexel mid-year 1999 a move that would have created the worlds largest CRO and a formidable rival to Quintiles characterizes well the intensity of consolidation pressure. In light of signs that the US market growth is slowing, one can expect to see continued diversification and consolidation. Introducing the CRO Only ten years ago, the term CRO connoted poor quality and high costs. Usage of contract clinical services at that time was low as only the boldest of pharmaceutical companies would use CROs, typically for the most difficult clinical research projects the dregs of the development pipeline. Health care reform in the mid-1980s began altering the economics of pharmaceutical R&D and forever changed the use of outsourced clinical services. Faced with escalating drug development costs, pharmaceutical companies looked for ways to manage their internal resources more effectively. Companies began shedding fixed costs in order to boost their profitability and to improve their return-on-investment in long-term, typically high-risk development projects. Between 1991 and 1995, pharmaceutical companies cut more than 45,000 jobs. Although most cuts were in manufacturing, administrative, and marketing functions, it is estimated that 7% of the total reductions were in R&D areas. At the same time, due to regulatory and market pressures, the scope and complexity of clinical projects increased. For example, between 1990 and 1995, the average number of studies per NDA almost doubled, and the number of procedures conducted in a given study increased by as much as 30% in Phase II development. Pharmaceutical companies turned to CROs as an experienced, variable cost resource. In essence, the CRO industry has evolved as a surrogate clinical operation where standard development practices were not altered. Rather, the CRO offered cost-effectiveness and greater efficiency by utilizing its capacity more fully across multiple sponsors and multiple projects in development. To date, an estimated 300 CROs have emerged in the US and Canada to meet the resource management needs of pharmaceutical, biotechnology and medical device companies. Despite the large number of CROs, nearly half of the total worldwide market is controlled by the top five CROs. Two of the largest providers of preclinical and clinical services Quintiles and Covance are almost three times the size of their next nearest competitors Parexel and PPD. An average of approximately 23% of a pharmaceutical companys development spending is outsourced to CROs with the lions share 69% going to contract clinical services; 32% going to contract preclinical services. Presently, pharmaceutical companies claim that CROs are playing a significant role on more than 60% of all development projects with usage the highest in phase III. Sponsors use CROs more frequently for traditional activities such as study monitoring and data management & analysis. However, CROs are increasingly used more broadly for a variety of pre- and post-study conduct activities including development planning, protocol design, investigative site selection, case report form development, patient recruitment, CANDA preparation and NDA dossier preparation. Over the past several years, pharmaceutical companies have entered into longer-term relationships with CROs in order to ensure preferential pricing and treatment. Although analysts vary widely with regard to projected CRO industry growth and market potential, most estimates are nonetheless optimistic. Five-year projected annual growth rates range from 15% up to as high as 20%. Several trends are expected to fuel continued growth of the CRO industry: specifically, (1) an unprecedented level of productivity now demanded by pharmaceutical and biotechnology companies; (2) the maturity of the biotech industry and (3) the growth of truly global development projects. (1) The Productivity Challenge. Following a brief period in the 1990s characterized by cost-containment and slower growth, the pharmaceutical industry has now returned to health. Worldwide pharmaceutical sales for prescription drugs will exceed $100 billion this year. According to PhRMA, sales are forecast to grow at 7% to 9% annually for the next five years. Industry profitability, now at 15% after-taxes, has been rising steadily since 1992. And industry is developing its drugs at an accelerated pace. PhRMA, reports that this year the ethical pharmaceutical industry broke the R&D expenditure barrier, contributing an average of 21.2% of sales to research & development. Todays market reality is no longer about cost containment and speed to approval alone. Essentially, the pharmaceutical industry is re-deploying resources in anticipation of a new primary challenge: How to sustain high revenue and earnings growth. A recent Lehman Brothers analysis finds that a major pharmaceutical company in order to sustain a 15% return on R&D investment will need to introduce nearly three NDAs annually that are capable of reaching $400 million average sales in their peak years. Based on historical performance, very few companies can hope to introduce that number of NDAs, let alone NDAs capable of achieving peak sales in the $400+ million range. Yet these aggressive innovation goals pose a necessary productivity challenge. Major pharmaceutical companies are scrambling to fill their pipelines. Companies are relying on new technologies e.g., genomics and combinatorial chemistry to identify novel drugs faster. Many companies are acquiring biotechnology firms or entering into alliances with them. A number of companies are entering into drug-licensing arrangements with biotechnology or with other pharmaceutical companies. Pharmaceutical companies are making heavy investments in building sales forces targeting the physician. And due in part to eased FDA restrictions, drug companies are spending heavily on direct-to-consumer advertising. Scott-Levin Associates estimates that industry will spend approximately $2 billion in directto-consumer drug advertising in 2001, up from $596 million in 1996. Armed with the promise of (a) a rich and large pipeline of new molecular entities and (b) a favorable market climate, sponsors are turning to CROs to assist in developing and launching new drugs rapidly and cost-effectively. As one industry executive recently stated, Our ability to maintain a high level of output is extremely dependent on CROs. (2) A Maturing Biotechnology Industry. The biotech industry now contributes 39% of total commercial R&D spending, and this is growing at a rate of 14% annually. It is widely accepted that the biotech industry has an even greater need to outsource to CROs given its relative inexperience managing clinical research projects. More than half of all biotech compounds in development have not yet reached phase II clinical research. Medical device manufacturers may also increasingly turn to CROs for development assistance as FDA requirements become more stringent. (3) Growth in Global Research Projects. Pharmaceutical and biotechnology sponsors are undertaking a growing number of global development projects due both to increased regulatory acceptance and development time advantages abroad. Today, it is estimated that one out of five projects involve a significant amount of data collected from investigative sites abroad. A number of CROs such as Quintiles, Parexel, PPD Development, Kendle and Covance are well positioned globally and they are expected to play a large role in assisting sponsors in meeting their international development objectives. A Volatile Operating Environment Along with promise for continued growth, the CROs operating environment is changing dramatically. High visibility among the investment community, for example, presents a new challenge for the publicly-traded CROs. Not only do they face growing pressures from clients and competitors; but also they must now address the demands of their shareholders. Rapid growth and investor optimism has facilitated intensifying competition, CRO market consolidation and increased pricing pressure. The competitive landscape for all CROs has changed. It is becoming increasingly difficult for mid-sized, full-service CROs to compete and succeed in the current environment. As a result, it is widely anticipated that the market will see considerable M&A activity primarily within the mid-sized CRO segment. An analyst report recently commented, the fragmentation that exists in the CRO industry cannot be sustained.

In the period 1996 to 1998, well capitalized and armed with high stock valuations, the large publicly-traded CROs aggressively acquired other contract services companies. Whereas many acquisitions were in traditional CRO service areas, the largest CROs also pursued forward and backward integration strategies. For example, most of the publicly-traded CROs expanded their range of preclinical and data management services, as well as pharmacoeconomic service capabilities. During that period, Quintiles was consistently a major driver of acquisition activity in the CRO industry as the company has pursued an aggressive vertical integration strategy. In 1996 Quintiles acquired Innovex, a contract pharmaceutical sales force. In 1997, Quintiles purchased a patient recruitment advertising and communications company. In 1998, Quintiles acquired more than 15 companies most notably the Envoy Corporation, a healthcare data interchange and data mining company. In December of 1998, Quintiles purchased assets from Hoechst Marion Roussel. In 1999 and 2000, Quintiles continued its push into medical informatics, genomics, and contract sales and marketing. Although less aggressive than in 1998, acquisition activity throughout 1999 was steady driven largely by top-tier CROs expanding their service offerings and geographical reach. During this period, top CROs acquired 13 companies, compared to a total of 26 in 1998. CROs continued to build their core CRO services businesses through traditional acquisitions in 1999. For example, Applied Analytical acquired MTRA, a midsized CRO, and Kendle acquired a French CRO, ESCLI. However, CROs are also venturing into strategic alliances and non-traditional acquisitions in an effort to differentiate themselves from the competition. Two top CROs entered into the pharmacogenomics market. Quintiles marked its entrance into this market by signing an exclusive agreement with Variagenics, a pharmacogenomics company. PPD Development built on its existing pharmacogenomics presence through a joint venture with Axys Pharmaceuticals. The two companies formed a new company, PPGx, which will offer comprehensive pharmacogenomics products and services to pharmaceutical and biotech companies. Other CROs continue to expand into non-traditional services, such as post-regulatory approval services. Quintiles broadened its contract sales division once again through the acquisition of MedCom, a provider of physician meetings and educational events. Quintiles also expanded its service portfolio by acquiring MediTrain, a sales representative training organization. Parexel built on its post-marketing activity by acquiring Groupe PharMedicom, a Paris-based provider of post-approval marketing support studies and regulatory services to pharmaceutical companies. Abruptly, in the middle of 1999, the public market for CRO services experienced a major downward correction. Subsequent acquisition activity by the publiclytraded CROs tapered off dramatically. Much of this correction is due to market pressures that are chracteristics of a maturing marketplace (e.g., competitive intensity, pricing pressures). Most acquisitions in late 1999 and throughout 2000 have been in more traditional areas with purchases primarily for core CRO service providers. As a percentage of total acquisitions made by CROs, in 1999 and 2000, a relatively small proportion were in strategic areas like drug discovery, medical informatics and pharmaceutical marketing and sales. Merger activity among major pharmaceteutical companies in late1999 through 2000 greatly increased CRO market volatility. Based on an analysis of 22 major mergers since 1988, CenterWatch found that R&D activity is significantly reduced up to three years post merger. For the large publicly-traded CROs, project cancellations and suspensions have been devastating. In early to mid-2000, many of the largest publicly-traded CROs announced major downsizing of their contract clinical divisions. In March, Parexel announced it would terminate 475 positions, and Quintiles announced that 800 positions would be eliminated. Then in May, Covance and Kendle announced that 200 and 125 positions respectively would be elimiated. The results of this CenterWatch analysis show that although merged companies aspire to increase their average number of novel NDAs annually, this is not happening. Whereas the average cumulative level of original NDAs is three per company pre-merger; three years post-merger, the average number of original NDAs drops down to two, a decline of 33%. One year post merger, there is a sharp rise in the number of original NDAs, but this is short-lived. Given pressure to generate larger numbers of original NDAs annually, this finding suggests that mergers will initially make it more difficult for companies to increase their productivity. Short term, merged companies appear to slow down their rate of R&D spending substantially. The cumulative pre-merger rate of increase in R&D spending per company is 7.7%. One year post merger, R&D spending levels per company grew slightly more than 3%. Three years post merger, R&D spending returns to premerger levels. Despite pre-merger announcements to the contrary, therapeutic area focus of product pipelines does not expand after a merger. Three years out, merged companies tend to have greater TA focus than a cumulative pre-merger pipeline. The number of clinical projects declines after a merger. Pre-merger, companies carry an average of 43 clinical projects. One-year post-merger brings a 10% rise in clinical projects. Three years after the merger, however, the average number of clinical projects decreases 9% below the cumulative pre-merger level, and nearly 20% below the short-term post merger level. During this period of high market volatility, there has been a shift in outsourcing philosophy and practice among sponsor companies. Mid-sized and small private CROs report that they are seeing growing receptivity among the sponsors that they work with. This quiet transformation has occurred while the publiclytraded companies frequently made the headlines in the popular press with announcements of mergers, acquisitions and partnerships, the closing of major contracts, position terminations and adjustments in valuations by the capital markets. Many mid-sized and small private CRO service providers are winning primary demand for their services by offering therapeutic area focus, service quality, and highly personalized attention. Competition for new clients has intensified with the largest CRO companies vying to out-muscle the smaller players through aggressive marketing and business development. New Entrants The CRO industry has had hardly a chance to notice or anticipate the inevitable entrance of well-positioned and well-capitalized new comers. While major CROs have been distracted, the window has been open for advertising agencies with strong healthcare businesses to buy share of the CRO market. Industry analysts expect increasing advances from advertising agencies and allied health service organizations into the relatively attractive drug development arena. In late 1999, multibillion holding companies the Interpublic Group (IPG) and the Omnicom Group completed acquisitions and minority investments in mid-sized CROs. These diversified global advertising agencies bring strong international positioning, resources and client relationship to their CRO subsidiaries. IPGs Lowe Healthcare Worldwide made its bold move into the CRO industry in early November 1999 through the acquisition of privately held International Pharmaceutical Research (IPR) a CRO based in Norwalk, Conn. Terms of the deal were not disclosed, but IPR has about 100 employees and revenues estimated at $10 million. IPR is a full-service CRO. The Lowe Group is one of the top five largest global advertising agencies with billings of more than $4 billion and offices in 80 countries. IPG also owns McCann-Erikson, another top ten global advertising agency. Lowe Healthcare Worldwide the health care advertising division is based in New York City and had billings of $452 million, ranking it fourth in the United States and ninth globally, according to MedAd News. Lowe Healthcare has offices and affiliates in 13 countries. Lowes clients have included Johnson & Johnson, Hoffmann-La Roche and Schering-Plough. Scirex, a CRO-SMO hybrid, entered a strategic partnership with global marketing communications firm Omnicom Group. Omnicom Groups Diversified Agency Services (DAS) invested more than $20 million in Scirex for a minority stake in the four-year-old CRO. Scirex, also a full-service CRO, has 500 employees globally. Omnicom Group is composed of three of the top ten global advertising agencies: BBDO Worldwide, DDB Worldwide and TWBA Worldwide. Omnicoms DAS operates independently branded companies in marketing services and communications. Another Omnicom division, Communicade, has majority and minority investment interests in interactive and new media companies. Omnicom boasts several hundred offices spread out across almost 100 different countries. In total, Omnicoms healthcare companies have about $340 million in revenues. Those companies range from medical education, managed care consulting to data analysis. Omnicom is publicly traded on the NYSE and had annual revenues of $4.1 billion in 1998. To date, most CROs have acquired or explored offering capabilities in every area of contract clinical service with the exception of the study conduct arena. Only a handful of CRO companies most notably Omnicare, Scirex and Ingenix own and operate research centers dedicated to conducting clinical trials. Most CROs are reluctant to offer integrated project management and study conduct services. Though this area may represent a promising approach to accelerate clinical development cycle times and therefore meet the needs of the research sponsor. Specifically, an integrated project management/study conduct provider might offer accelerated study initiation, patient recruitment and data collection relative to the traditional approach (e.g., sponsor or CRO contracting with autonomous investigative sites). Opponents of an integrated approach cite operational challenges and the difficulty in using research centers owned by competing CROs. Pharmaceutical companies continue to pressure CROs to offer greater speed, reduced cost and improved service quality. The CROs ability to manage its own rising fixed costs is contributing to consolidation both among peer companies and among investigative sites. CROs are not only working to achieve greater operating efficiencies, they are transferring more of the financial risks to the investigative site. At this time, CROs are pressuring investigative sites to deliver unprecedented performance at competitive costs.

CROs have contributed greatly to the commodatization of research centers. And this has placed significant strain on a relationship dependent upon collaboration. In surveys conducted by CenterWatch, CROs receive only mediocre ratings with regard to relationship quality. More than one out of three centers perceive their relationship with CROs as Fair to Poor. In addition, research centers perceive almost half of all study conduct delays caused by CRO inefficiencies. Investigative sites have also complained that CROs are squeezing them, making it virtually impossible to perform profitably and to manage their cash flow while maintaining high quality standards. As a result, investigative sites argue, access to patients and the quality of patient care will suffer. Pharmaceutical companies are beginning to hear these negative perceptions expressed by research centers. Sponsors are reevaluating the trend toward increased outsourcing particularly in light of the challenge of recruiting study participants. Given the importance of meeting the sponsors patient enrollment objectives, a strained relationship between CRO and investigative site is significant. CROs and investigative sites share views on the importance of rapid patient enrollment as it is the largest determinant of repeat business. Recent Shifts in CRO Usage A recent CenterWatch survey of major pharmaceutical companies reveals that sponsor outsourcing practices have been shifting. Although usage levels remain high, sponsors are not increasing the overall level of CRO involvement in their clinical projects. Instead, they are using CROs for a broader range of clinical activities. Sponsors are directing their spending dollars to a much wider and more diverse pool of outsourcing partners from full-service to small niche players. Essentially, sponsors have become savvier multi-vendor managers. This combination of rising clinical spending and changing sponsor outsourcing practices will drive CRO service provider segments to pursue very different strategies in 2002. The large, full-service CROs will face higher levels of competition from leaner and more nimble niche and mid-sized players. These large organizations will pursue strategies designed to help them look and operate like their focused and niche-oriented clinical service counterparts. The mid-sized, small and niche CROs face the challenge of managing their growth while maintaining focus on those services that have secured their relationships with sponsors. Sponsors responding to our survey also present ambivalence around the rising costs of CRO contracts and the variability in service quality. The persistent challenge to control costs and improve quality is leading sponsors to continually search for better ways to manage their outsourcing partners. Sponsors continue to use CROs for a high percentage 61% of their clinical projects. This past year, Wall Street analysts were sharply divided in their speculation that industry would see either a short-lived decline due to merger-related disruptions or an unprecedented increase due to capacity demands. Neither speculation materialized. Instead, CRO usage levels in 1999 and 2000 appear to have reached a plateau. This is the first time when sponsors have reported using CROs at levels consistent with those reported two years ago. Overall, sponsors are largely bullish on CRO usage during the next five years. Nearly two out of three sponsors expect that their use of CROs will increase Somewhat or Greatly in that time period. Slightly more than one-third of sponsors expects CRO usage to stay the same. Less than one out of ten sponsors expect CRO usage to decline in the coming five years. Sponsors report that they use an average of five CROs regularly. This number is consistent with the results gathered from our 1998 survey. Also consistent with this earlier survey, CROs are used most often for phase III programs with phase IV involvement a not so distant second. In the recent survey, it appears that sponsors have increased their use of CROs for phase II activities. This is due in part to capacity requirements and to growing numbers of biotechnology companies now seeking clinical expertise for compounds now in phase II. Also consistent with prior surveys, CROs are involved less frequently in the planning phases of clinical projects. Sponsors tend to outsource site management and data management activities far more frequently. CRO involvement in planning activities such as development planning, protocol and case report form design is highest in post-marketing projects. Sponsors report using CROs for site and data management activities most often in phase III. Relative to all other phases, sponsor use of CROs in phase I is typically lowest across most activities with the exception of development planning and protocol design. Sponsors report that their outsourcing levels for study monitoring and statistical services the two largest spending categories have held steady. Sponsor use of CROs for development planning and protocol design are also consistent with 1998 levels. Seventy-five to 80% of sponsors choose to handle these activities inhouse as they afford higher levels of control over the clinical project. Today, sponsors report that they are using CROs far more frequently for site management activities. For most investigative sites looking to increase their direct interaction with the sponsor, this has no doubt been a major source of frustration. Historically, investigative site relationships with CROs have been strained and inefficient. Two years ago, sponsors said that CROs selected and managed sites approximately one-third of the time. In our recent survey, sponsors report using CROs to select and manage sites for nearly two-thirds of phase I-IV projects. In Phase III specifically, CROs are being used to manage and select investigative sites nearly 90% of the time. In phases II and III, sponsors are also turning to CROs more frequently for their assistance in recruiting patients. These results have strong implications for investigative sites, as they will need to more proactively develop their business relationships with a diverse set of CRO service providers. Just more than half of sponsors responding to the CenterWatch survey believes that CRO costs are becoming more expensive. The other half feels that costs are holding constant. None of the companies completing our recent survey perceive that CROs are becoming less expensive. These results are consistent with those gathered in 1998. Unlike our earlier surveys, however, a larger percentage now perceive that CRO costs are in line with the costs expended for in-house resources. In 1998, the vast majority 92% of sponsors perceived that CROs were as much as 50% more expensive. In the recent survey, slightly more than two-thirds (69%) share this view. CRO service quality is another area where sponsors express mixed opinions in our recent survey. A slightly larger percentage of sponsors appear satisfied with the service quality that they receive today relative to that which they received in 1998. Forty-one percent of sponsors perceive that CRO service quality over the past two years has stayed the same. Nearly 30% of sponsors feel that CRO service quality has improved somewhat. An equal percentage perceives that CRO service quality has gotten worse. In our 1998 survey, more than 40% of sponsors felt that service quality had gotten worse. Nearly 60% of sponsors expect average CRO contract size to increase over the next couple of years. One in five sponsors surveyed expect average contract size to decrease. In our 1998 survey, a smaller percentage 49% of sponsors said that they expect increases in average contract size. Typically, sponsors are inviting four CROs to bid on their projects. Three years ago, sponsors reported that an average of three bids was solicited per project. The majority of sponsors 71% report that they have established preferred provider agreements with an average of three CROs. At the present time, most major pharmaceutical companies have centralized outsourcing management departments. But only half of sponsors state that this department makes the final selection decision. In our 2000 survey, nine of the 17 companies said that a member of the project team ultimately chose the CRO partner often with guidance or input from the central function. The CRO selection process is perhaps the area of greatest change in sponsor outsourcing practices. In the 1998 CenterWatch survey, sponsors reported that CRO reputation and cost were the top selection criteria. At that time, more than half of sponsor companies rated these two factors as Essential. In our recent survey, only one out of 17 sponsors rated cost an essential factor. Approximately 60% of sponsors rated Therapeutic Area Expertise and a CROs Ability to deliver patients as Essential criteria. Conclusions Growing numbers of sponsors show interest in working with a diverse pool of contract project management providers. Eight out of ten sponsors indicate that they expect to increase their use of smaller and more focused service providers over the next several years. Although sponsors have mixed impressions about CRO service quality and costs, most are using CROs frequently for a wider variety of activities and clinical phases. Sponsors are putting in more effort to securing competitive bids and to selecting prudently those CROs that can provide a particular area of expertise. By assuming a role as a manager of a multivendor team, sponsors are relinquishing their ability to simply hand a study over to a single CRO. In order to achieve quality and efficiency, sponsors are finding that they must play a far more proactive project management role. At the same time, there is still a high level of variability among sponsors in terms of how much they rely on outsourcing and in their beliefs on how to best use CRO service providers. The one constant in all of this variability is the ongoing pursuit for drug development efficiency. Sponsors will continue to pursue outsourcing strategies and opportunities for accelerating drug development and maintaining high quality standards while reducing costs.

The growth prospects for CRO companies within clinical R&D appears strong. The underlying issue CROs face is where to go to sustain historical growth rates above 20%. CROs are pursuing a wide variety of opportunistic strategies designed to accelerate the R&D process and to enhance the commercialization of drugs and medical devices. Although the CRO industry is expected to enjoy rapid growth, CRO companies will likely share unevenly in this growth. Major pharmaceutical companies are becoming more sophisticated in their management of contract service providers. CRO management functions including vendor identification, selection and negotiation are being conducted more systematically in many cases these functions are now centralized within pharmaceutical firms. As a result, the level of competition for project management contracts will greatly intensify. Given the sponsors needs to flood the drug pipeline, achieve a high level of collaborative efficiency in development and to rapidly launch products into the market, the coming years will bring a great deal of change in the market for CRO services. References: Articles from the CenterWatch newsletter CROs: The Role of the Middleman is Growing, Volume 2, Issue 1, January 1995 Cracks in the Partnership, Volume 2, Issue 4, October 1995 The Booming CROs, Volume 3, Issue 2, April 1996 Here Come the Hybrids, Volume 3 Issue 5, October 1996 Taking the Measure of CROs, Volume 4 Issue 1, February 1997 Sponsors Send Mixed Message to CROs, Volume 5 Issue 2, February 1998 Quintiles Separates from the Pack, Volume 6, Issue 2, February 1999 CROs Raise the Grade, Volume 6 Issue 4, April 1999 The Changing Face of Hybrid Providers, Volume 6 Issue 8, August 1999 Correcting the Public CRO Market, Volume 6 Issue 11, September 1999 A Quiet Transformation for Private CROs, Volume 7 Issue 5, 2000 The Cost of Pharma Mergers on Clinical Research, Volume 7, Issue 6, 2000 Assessing Change in CRO Usage Practices, Volume 8, Issue 1, 2001 Getz, Kenneth. Strategic Sourcing: Were Not There Yet. Applied Clinical Trials. June 1998, Volume 7, No. 6. Pgs 40 42. Source: Ken Getz, President, CEO, and Publisher, CenterWatch, 22 Thomson Place, Boston, MA 02210, Tel: 617-856-5940, Fax: 617-856-5901