PM360 MAY 2011

PM360 ROUNDTABLE Moving Forward on Adherence

Our Trailblazer Brand Manager winners got together before the awards ceremony in New York late last year to share their insights from various therapeutic categories about the thorny issues of patient adherence, compliance, and persistence. PM360’s Common Sense columnist, Bud Bilanich, moderated the discussion. Here are their comments on topics ranging from ROI and the multi-channel mix to the patient-physician dialogue and behavior modification.

BUD BILANICH
PM360’s Brand Manager
Roundtable Moderator

ANDREW WATSON
Director of Marketing
Wockhardt USA
awatson@wockhardt.com

Bud Bilanich: How important is compliance and adherence to your company and its brands? How do you approach it?

Joe Shields: It’s unlikely that many patients will achieve their desired health outcomes without closely following their prescribed course of treatment. And it’s important to biopharmaceutical companies that their medicines are used according to the label, by patients that understand appropriate dosing and therapy duration for their particular situations, as prescribed by their HCPs. The biopharmaceutical industry has become more sophisticated over time in its understanding of how best to support patients at different points in their therapy, particularly for chronic diseases. We look at every angle and approach it as a multi-channel education and support program, as opposed to a single initiative in a single channel. The recent U.S. economic climate has also highlighted the importance of broadening access to medicines, so the industry has greatly increased co-pay and foundation assistance to reduce financial barriers to patient adherence.

Jeff Dierks: The industry uses the terms “adherence,” “compliance,” “persistency,” interchangeably but it's important to define what each one means. Compliance refers to people actually taking the medication prescribed by their HCP. Adherence, actually using it as a doctor prescribes, and persistence is how long I actually follow the course of therapy.

To Joe’s point, in each channel there’s a component of all three— adherence, compliance, and persistency— that really plays into the marketing. For compliance, how do you ensure the patient fills his or her medication. Once it’s filled, make sure the patient takes it the way the doctor prescribed it and for the duration it’s been prescribed for. There are a number of innovative things, from the web to retail pharmacy to personal promotion, to address all three areas.

Bud Bilanich: What percentage of your budget do you spend on compliance or persistence compared to your brand’s total marketing effort?

Glenn MacEachern: I know my company spends a lot, about 15% to 20% of any one of our budgets, particularly our budget for estrogen. For a small company like ours that’s trying to be successful in a very education-intense type of therapy, it becomes a struggle.

Joe Shields: Budget figures can be misleading—just because you're spending a small percentage of a marketing budget for adherence doesn’t mean you're not positively impacting many patients’ lives. The budget supporting adherence and better patient outcomes is focused on serving a relatively small number of patients taking Brand A, as opposed to the thousands or possibly millions that may be diagnosed with the same condition but not treating with Brand A or not treating their condition at all.

For some brands, the direct-to-consumer media spend for TV or print advertising dwarfs other budget line items, partly because media can be expensive, and partly because that media scales to reach millions of viewers at high frequency. So adherence programs tend to provide a higher level of service for existing patients, but the number of these patients is relatively small.

There are hidden costs, too. Operational costs that don’t necessarily show up as adherence costs, but in fact are. For example, 80% of the function of a call center may be to help existing patients and give them the financial, medical, and emotional support they need. There are also co-pay cards and other patient support programs that may show up in different parts of a brand’s budget.

Jeff Dierks: I think Joe’s right on. One thing we’re doing is asking what percent of the dollar spent on current patients goes to compliance and persistence, as opposed to asking what percent of the overall budget does. How much of that dollar are we investing in educating them about what to take, how to take it, why they’re taking it? This may be a better way to inform future investments in this area.

Bud Bilanich: Are some products in your company's portfolio better supported by adherence programs than others? If so, why is this?

Glenn MacEachern: When I launched a product recently, I wanted to include a very active compliance program, which required input from the sales rep when visiting the doctor. But there was concern from sales. They said: “I’m trying to sell a product. Now do I have to sell a compliance program, too?” The last thing I want is for the reps to have to sell a compliance program in addition to the product. So we need to look for gentler, kinder ways of engaging. Our focus needs to be on understanding the customer better and on simpler and quicker information.

Bud Bilanich: So while you do need to work through reps and physicians, you have to find other ways of getting to patients.

Marc Migliorini: There are several underutilized resources in healthcare delivery. We previously discussed the role of the pharmacist in patient education and medication adherence. We must also recognize the role of nurse practitioners and physician assistants in patient treatment. They not only prescribe medication but influence patients to stick to their prescribed therapy.

Jeff Dierks: There are a number of vendors that can provide insights into HCP-patient interactions, videotaping interactions between a patient and a doctor. The insights are illuminating —doctors are talking about disease state and medication regimens at a level that would make a patient’s eyes roll, really showing the challenges that exist for addressing adherence, persistency, and compliance. The research showed doctors spent on average 4.4 minutes with every patient, compared to 14 minutes for the nurse practitioners. The direction that came out of an NP interaction was much more meaningful and provided insights for future investments.

The research and insights really helped us sell new tools and messaging to the reps—the idea that by going in with this patient dialogue, you’re going to help bridge a gap. We invested a lot of money in doing nurse practitioner research and developed specific content, webinars, emails, and dialogue for them. So our reps literally have six or seven tools that are almost like a nurse practitioner toolkit.

Bud Bilanich: Are you finding that cost is a huge driver when it comes to adherence?

Glenn MacEachern: Cost will always be a problem. Whether in good times or bad times, you need to do market research to understand your barriers to success. If we can neutralize cost as a barrier to prescribing, that is one of the best things we can do. In the case of our estrogen product, I find that it isn’t about the cost most times. When you have an abandon rate as high as it is for prescriptions, it's probably more an issue of fear and education.

Jeff Dierks: One question is: Is cost truly a barrier to adherence or just to brand choice? Sometimes, maybe you choose in advance to stay on your therapy based on your HCP’s request; sometimes, you just choose a different brand or switch to a generic.

Bud Bilanich: Let’s put two questions together. What was the best investment you’ve ever made? And what program has produced the best results?

Andrew Watson: The best program I’ve done was with Cegedim Dendrite, where we had a co-pay program that was valid on the first script and then continued as long as the patient was willing to refill it. It helped overcome the cost barrier for cash-paying patients. It was expensive but had a tremendous impact on the confidence of sales reps and on the physician as well because it minimized cost push-back from patients.

Stuart Davis: We’ve had a lot of success on the retail refill reminder program. We were very, very effective because you could figure out when the drop-off occurred. One current program that I’m hoping will be effective is an electronic rebate card that you can get dollars off in the doctor’s office that will allow us to track compliance and persistency of the patient who’s returning because of our product. This will also provide the doctor with better information.

Jeff Dierks: Probably the best investment I made in an adherence program wasn’t actually in the program itself, it was the research behind it, to get at what was driving the adherence. We did lots of linguistic research looking at physicianpatient dialogue and overlaid with consumer segmentation to get at the most compelling messages for the brand.

Rather than providing offers for all our patients, we used our research insights to identify a target group of individuals over the age of 50 that skewed toward women who had a history of specific medications in the last 90 days. For that subset of patients, we generated a 12 to 1 ROI.

Marc Migliorini: To build off Jeff’s comments, most marketers take a shotgun approach in providing co-pay assistance programs. We distribute as many co-pay cards as we can through traditional distribution channels. The challenge is to better understand what motivates a patient to stick to their prescribed therapy. Most marketers don’t require patient opt-in and lose the opportunity for ongoing communication.

Joe Shields: For me, a successful program helps patients achieve their desired health outcomes in a measurable way. For some conditions like asthma, this may mean fewer trips to the emergency room. For others, it means keeping blood pressure or cholesterol under control to reduce the risks of stroke and other cardiovascular diseases. Yet sometimes it’s difficult to get these measures, so we use proxies that give us directional data.

We mentioned earlier that the pharmacist, the doctor, caregivers, and the patient all have a role in adherence, but there’s also emotional and informational support found in social media. Pharma companies have been slowly establishing a presence in social media, but in the meantime patients are getting advice from total strangers about very important aspects of their health.

Bud Bilanich: Does the complexity of the adherence problem require that every avenue be addressed by pharmaceutical adherence programs? How do you manage the mix?

Glenn MacEachern: I think they’re all important. The problem I have again is the resources. I can’t do all of this, so I have to sit down and challenge the managers and say, “So why is that the program you want? What do you expect to get out of it? How are we going to measure success? How are you going to benchmark it?”

Paul Huff: You need to define the problem precisely. If the problem is not that the patient forgets to take their medicine but rather it’s a disease-state education issue, then why would you employ a refill reminder program over and over again? If your target segment doesn’t use mobile phones, why would you use that platform? So part of it is having the discipline to define the problem just like in any other business, and then it’s a behavior modification issue.

Jeff Dierks: You hit it right on the head. You’re almost reverse engineering your marketing plan from the consumers’ lens: “What is making me non-compliant?” Figure that out and then reverse engineer the marketing program to focus only on those drivers as opposed to doing 40 things and hoping the aggregate effort works.

Bud Bilanich: What do you think or hope will come from the 2010 Patient Protection and Affordable Care Act in terms of patient adherence?

Paul Huff: The impetus for this question was that there are some provisions in the law about expanding health education, thus hopefully leading to better adherence down the line.

Andrew Watson: I would add the pharmacists to that group, too. If they could code for their time to have those in-depth discussions, that exchange of information would be invaluable to the pharmaceutical industry.

Paul Huff: Another part of the new Healthcare Act has to do with outcomes. In the future, the entire healthcare system will be paid more based upon achieving positive outcomes and increasing medication adherence. How do you think that might impact your brands?

Jennifer George: Jumping in from a medical device company perspective, I can say that all of our PMAs and our ABEs are required to have some type of outcomes information. We’re currently monitoring costs so we can come back and tell the consumer, “If you choose this treatment instead of this treatment, we’re going to save the government this much money.” It’s like our little wild card to play.

In addition, we’re getting hit with different rules in Vermont and Connecticut and other places that want us to report how much we're spending on doctors in their state. It's not clear whether this will be a long-term issue or not, but if it is, how does this change our dynamic? If we keep on getting taxed in all of these states for the physicians we work with, that will hurt our bottom line and change our direction. Do we just kind of roll over and say this is OK, or do we do something proactive?

Andrew Watson: One of the questions I have about the new law is whether it has any mandates on patients to start taking better care of themselves, to be more compliant.

Bud Bilanich: How do you get your hands around ROI on your adherence programs?

Joe Shields: When I think about measuring programs, I think of three levels. First, there’s the activity level. How many clicks, page views, registrations, or opt-ins did you get? That might be called the first level of success, though it may not really be success. Unfortunately, a lot of marketers stop here.

The next level up is the program level. This looks at individual programs that run for some period and measures what happened to a particular cohort in terms of length of therapy or some other parameter. Some people calculate returns on individual programs or compare effectiveness of different programs through marketing mix analyses.

Then there’s the strategic level. If your overall strategy is to improve adherence, there are third-party claims data or other sources that can verify that the length of therapy for a particular medicine has actually increased across all of its programs. In addition to better patient outcomes, days on therapy may be a good measure of the effectiveness of overall patient adherence efforts.

Stuart Davis: Brand engagement metrics are very important because they’re good indicators for the future. They indicate long-term ROI and brand loyalty. The benchmarking is important if it gives you some realistic expectations. But just because you did better on the benchmark does not necessarily mean you got an adequate return on your investment. That’s always the dilemma.

Jennifer George: I think medical device companies are really more focused on sales than on brand. So what we really measure is cost per lead and cost per sale. Of course, we also measure email and direct response upticks and impressions, click-through, and information requests on our mini-websites and things like that.

You’ve also got to have a really good CRM system because we have only 140 distributors plus full-time reps that cover the entire United States. So we are trying to help our salespeople. To do this, we have developed a CRM system to support an active kind of co-partnership with the reps. I’d also like to mention a trial project I’ve seen; Covidien is using an iPad and iPhone to collect metrics from the reps, tying that into a technology to create a stronger ROI.

Companies are also building their brand by improving customer experience and support. That’s actually causing an uptick in sales because the doctors find it easier to work with them compared to other companies. I think we’ll see that across the board in device.

Bud Bilanich: Do you think that’s something specific to med devices? Is there less need for CRM for pharmaceutical programs?

Jennifer George: If I can create a better experience for the doctors, so they don’t always need to meet with a sales rep to become educated on new products or can troubleshoot virtually through an online customer service rep, at midnight, if necessary, why not? Using technology to help make a doctor’s time more worthwhile makes sense across the board.

Glenn MacEachern: One thing we’ve done with our strategic partners, and not only for adherence programs, is to make sure that guidelines are set up beforehand. What are our expectations? What are we trying to achieve? That helps focus any ROI program. There are also some softer sides that we can look at. Are we getting great feedback from the reps, the physicians and other healthcare professionals? Are we getting feedback from patients? Those are softer, but yet maybe they can have an impact for us as well.

Bud Bilanich: Is there anything else that you'd like to ask that we haven’t been talking about?

Marc Migliorini: What’s the “latest and greatest” in reaching patients and influencing HCPs as we move into 2011?

Joe Shields: For me, it’s mobile. The penetration of smartphones has reached the point where it is fundamentally changing how people access and interact with healthcare services. What we’re doing is taking the assets we already have—website tools, call center expertise, and co-pay programs, for example— and pushing them to smartphones for both patients and physicians.

Jeff Dierks: We’re focusing on ethnographic research and really trying to understand the multicultural variances and differences. We have two topical products in our franchise, and we know that there are some cultural and ethnic preferences for topical medication versus orals. So we’re asking what types of media people in these populations consume—maybe newspapers in one and Univision in another. Then, too, translations of our content need to reflect the slang and terminology of the target population. So we're trying to find appropriate partners—like the Chinese or Russian National Medical Association—and get them involved in building a bridge to better communication. I think that will really help drive compliance in those audiences.

Stuart Davis: For us it’s really the patient-physician dialogue. The problem is that doctors are not trained to be salespeople or to educate patients about options. That’s a big disconnect, and if we can correct it, it will be a win-win for the doctor and obviously for the manufacturer. For example, if you ask a woman the wrong thing, she will say things or the doctor will say things that are insulting and they won't make the sale. So how do you have that dialogue in a productive way?

Andrew Watson: For us, one major focus will be on education on the PA/NP fronts because we recognize that they’re more accessible to us and they spend more time with the end customers. We also target the caregiver, the parent. We're trying to leverage the viral blogging and mom community to make sure the kids get the best-quality medicine.

Jennifer George: I think we’re past the days of investing in projects that would stretch out across multiple regions. In the Pacific Rim and other markets, you basically hone your messaging so it’s very local and work with the appropriate groups to design the best programs for these markets. This does mean investing in focus groups. It means traveling. You need to partner. You only have one chance to get it right with look and feel and messaging when launching a product in new markets.

India’s also an amazing market. There’s a lot you can try there already on the digital and communication side that we don’t have the luxury of doing in the U.S. There are many incredible applications for using technology like iPhone apps to educate physicians in India.

Glenn MacEachern: For us there are four clear initiatives across multiple brands. One is how we use unbranded campaigns. How do we make them more educational and impactful for patients across the spectrum? We’ve also ventured out a few times with NPs and PAs. This area is a hot button for our brands and sales partners. A third point would be any kind of digital communication. Despite changing FDA rules, our legal and regulatory departments need to help us establish boundaries and set some guideline to move forward in the digital promotional space until the FDA provides a clear guidance.

Finally, I’m finding that sales very much wants to be part of the technology drive, using the iPad, for example. What I don’t want is a visual aid shoved into a fancy box, and that’s what I find a lot of. That’s not improving the communication of our messages. What we need to do is use technology to maximize our platform and our discussion.

The opinions expressed by the authors in the Think Tank section are their own and do not necessarily reflect those of their affiliated companies or organizations.