Six of PM360’s 2011 Trailblazer Brand Manager Award winners joined us just before the awards ceremony to discuss how to build and maintain brand loyalty in an increasingly complex market. Common Sense columnist Bud Bilanich moderated the discussion, which moved from a dissection of the basics of loyalty to an appreciation of the emerging importance of customer service.
This Roundtable is sponsored by: OPUS HEALTH, a division of Cegedim Relationship Management
Let’s look at the components of brand loyalty. Classically, it’s built on customer satisfaction, perceived value, cost benefit, and the independent value of perceived benefit. Do traditional ideas of brand loyalty apply in this industry, or are they different?
I’m working on this concept now. Plavix is losing its exclusivity [in May 2012], and it’s a fairly big event for the company as well as the industry. We challenged our team as to whether or not there was brand loyalty post-LOE for this product. Going into it I thought, “Not likely.” We conducted some market research and ironically there was a lot of brand-loyal patients and physicians. We found that there is a perception, a belief—created in the marketplace by our marketing and our salespeople—that patients need this drug to survive, to not have a heart attack, to keep their stent open. But how far does that go? Initially, the marketing team believed that as soon as generics were available, there’d be nobody fighting for it. So now we have identified brand loyalists, but how do we get them that drug?
You’ve done a tremendous job with your animation. It is one of the best examples of clearly illustrating what the product does.
If you take it down to the next level, there’s a fear that drives patients who have just had a heart attack or a stroke. And we have tapped into that subtly. Can the competition including generics knock it down? Maybe. It is yet to be seen.
But isn’t that, too, the perceived value: it’s been around for a long time, it has a history, you see it on TV. Doesn’t that mean to the patient that the product is more stable? And I think a lot of people will look at that and choose it over something new and unfamiliar. There’s still that perception of, “Oh, it’s a generic.”
Brands work in those instances where the patient can say, “This product could potentially save my life. I know it’s working. Why in the world would I risk switching to a generic?” But for most drugs out there, the patient doesn’t always see what the real benefit is. That makes it a lot easier to either discontinue treatment, which is a huge obstacle, or you know, switch to that generic.
Last year we talked a lot about adherence, and about patients discontinuing treatment because they couldn’t see the effects.
Yes. Some studies show that, across various disease states, within a couple months up to 70 percent of people discontinue treatment. Is the real enemy the risk that patients are going to switch to another product, or is it that they’re going to discontinue treatment altogether?
Or not even start therapy. Twenty percent of all prescriptions don’t make their way to a retail pharmacy.
And not all of that’s because of access or health insurance.
No, they just don’t believe in the therapy. When they walk out of their physician’s office, they’re thinking, “I don’t have concordance with the prescribed therapy. I don’t think I need it.”
So we see that in vaccines all the time. We have recorded transcripts where the doctor says, “You need to get this vaccine,” and the patient says, “No, I don’t want it.”
I’m hearing people agree that brand loyalty is certainly a factor a) when you can clearly communicate what the product is doing, and b) when patients are aware of the consequences of not adhering to therapy.
There are different channels. So brand loyalty for a physician versus a patient means different things. When a patient fills that first script, have we gotten brand loyalty from them yet? Probably not. But for the physician, I think that is where it starts. It’s different.
That’s our biggest challenge. Patients confuse a rescue inhaler with a maintenance inhaler. What’s the difference? And we have the better adherence than our competitors, even though they have dual indications for asthma and COPD. But 50 percent of patients still drop off in three months. So our challenge is “How do we bring more value, especially with the market becoming much more competitive?” So we’re going through this exercise now: What would it take to say, okay, beyond the pill? We’re looking at patient support programs. One of the things we’re trying to stay away from—I’d be interested in your feedback—is coupons. Often, the first reflex is to start throwing coupons out there. We’ve done that, and we’ve seen that it really doesn’t impact your adherence if you just do a coupon. Whether you do a copay card for 12 months or 3 months your adherence isn’t that much better. As soon as that’s done they drop off.
But you are finding that patients are asking doctors for Spiriva.
We are. I think it starts with the physicians, once they’ve got brand loyalty.
That’s a very active group on the internet, COPD sufferers.
Yeah, they are. It’s amazing. The average COPD patient is usually 60-70 years old. You might not think of them as internet users, but it’s the exact opposite. We have much more focus in digital than we’ve ever had in the past. People search and there’s a ton of COPD [information on the Web]. And it’s growing since the market’s just getting so big. There’s so much more out there than ever before. Our big challenge is, when people are talking, how do we get there? We all have our regulatory concerns and we can’t play in those spaces right now.
Bud, earlier you said, “Hey, I love that animation. It really shows what you did.” I think what everybody here is saying is that it’s education. It’s getting the patient and the physicians to understand what it is, how you use it, what are the benefits, why you would you use this instead of something else. We focus on that a lot in the training programs provided for reps and doctors, so that they really understand and can explain it. That’s the only way we’re going to get where we want to get and where a lot of you guys have gotten already— making it simple and breaking it down.
Let me throw out a contrarian view. If brand loyalty exists at all, I would say that it only exists during the patent protection period. And once that patent is gone—and you see the generic erosion rates—it goes out the window.
Once you get into the generic marketplace, sustainability is difficult. So you have to address those other barriers: pricing barriers, access barriers. If you don’t address those, the whole brand loyalty can fold pretty easily. I think Coumadin may be the one example where you truly have a differentiated benefit. So patients could actually suffer bleeding or a stroke if they’re not maintained within the therapeutic INR [international normalized ratio clotting-time] range. If you switch from a generic to another generic, each time you go to the pharmacy it’s a different drug, and clotting times fluctuate. A truly differentiated clinical benefit and value have maintained the Coumadin business for quite a number of years post-LOE with a fairly solid market share. Today when there are multiple generics it becomes even more difficult. The infrastructure in retail pharmacies really is increasingly tough, as they make more money dispensing generics versus branded agents.
We have a similarly resilient product at our company, Synthroid, that is a good example. It has a narrow therapeutic index. It’s been generic. However, there’s still a lot of brand loyalty to it. My point is that it differs between customer groups. And a payer—is there brand loyalty from a payer’s perspective?
General Response: No, absolutely not. Not at all.
It’s all about best price, right? There are probably 40 to 50 generic equivalents to branded Synthroid, and yet Synthroid keeps a good market share because of the way the body absorbs that drug in particular. That’s the reason for brand loyalty: some patients fail that therapy on the therapeutic equivalent and they come back to the branded product.
It comes back to that earlier point of feeling the difference in products. You have to go to the doctor to measure your blood pressure to make sure it’s going in the right direction. You might not notice your daily fluctuations. Consider two patients who have had thyroid cancer. Both have gone through a bunch of different thyroid hormone replacement therapies, and they were always off one end or the other. But when they landed on a therapy that worked, that’s the one they stuck with. They could feel it really having an impact on their daily life. Once you find the thing that makes you feel good, you stick with it. But if you can’t tell that it’s actually doing something, it’s really easy to switch.
Does that apply in devices?
Well, it does. When you talk about removing barriers for our products, certainly barriers are cost, understanding of where the product fits in the continuum of care, reimbursement—huge. So a lot of it is the same. As I said before, it’s about the education and, as you just said, removing the barriers to purchasing when somebody says, “You mean this doesn’t have its own code yet?” We have to have our own reimbursement team that will fight the fight for our doctors, fight the denials and things like that. So we try to do lots of things to remove the barriers as they crop up.
Getting back to the first question, brand loyalty definitely exists in pharma. Now, you do have certain complications, like patent exclusivity and loss of exclusivity. Consider somebody who will be loyal to a brand like Lopressor regardless of what I may tell them, and I’m a pharmacist. I may say that there’s no difference in efficacy, and that going generic is cheaper. But it doesn’t matter: there’s something going on, an emotional benefit that’s as important as the physical benefit. If the product’s doing the job for you, you don’t want to switch and open yourself up to that gurney that’s following behind you. It’s the same in the consumer markets as well, right? If we’re consumers and a product is not delivering for us, we’re going to look somewhere else.
Let’s talk more about the emotional part of it. I think most brand loyalty’s based on emotion. I’m a Jeep man, and my wife is a BMW woman. It’s not based on logic. How else does this apply in pharma?
Here’s a little story. I was taking a cab in Florida, and the driver asks, “Oh, who do you work for?” I say, “Abbott.” He says, “Oh, I love Abbott,” and I said, “Well, why is that?” He says, “Well, my daughters, they were on Similac, they’re on PediaSure, Pedialyte.” He just thought of Abbott as the commitment to health. A product has a limited time frame. You have 20 years, but a lot of that’s eaten up by development time. Then you have a short window for marketing the product. So tying back to brand loyalty at the company level produces a halo effect. We all know the adherence rates. People drop off a therapy after a month or two, and when you get down to six months hardly anybody stays on any of our therapies. Why is that? Are there different curves and different “loyalty” depending on the indication or disease state you’re dealing with?
We’ve said this a couple of times. If you can measure it—the therapeutic effect as with INR’s, blood pressures—then you’re ahead of the game, right? If you’re constantly being measured as with Coumadin, we’ve engrained the concept “You’ve got to be between these values” in the patient’s head. Patients tend to pay a lot of attention to the guidance their physicians give them. And then we have a Plavix, which you don’t necessarily measure. The measurement creates an emotional tie. Measurement can lead to brand loyalty.
We’re in a bit of a unique situation with an orphan drug. We were the only player in town for preventing attacks of hereditary angioedema, but since our approval we had three players come onto the market. They’re all injectable drugs, like ours, but they’re for treatment of acute episodes, not prophylaxis. We don’t consider them direct competitors —but they are. It’s a very small patient pool and they’re all therapies indicated for this one orphan condition. You rarely have that situation for an orphan condition, with four players suddenly on the market. The disease affects people differently and there’s a whole range of severity and frequency of attacks, so there’s a gray area where patients could either go on our therapy for prevention (some just have to be on prevention because they have so many attacks) or they could decide, “Well, we’ll wait till an attack occurs and then we’ll go on one of these acute therapies.”
So we’ve tried to prevent any switching from prophylaxis to acute treatment by anticipating patients’ physical and emotional needs. We know the product addresses their physical needs by preventing attacks. We try to anticipate what some of their emotional needs are, what living free from attacks means to them, and then tailor our marketing and our messages towards reinforcement of that feeling. “You’re on Cinryze. You’re not having attacks. Now here are some steps that you can take to continue your attack-free life.” And then we provide them tools and resources to help them do that, so now these patients are able to travel, when they never could before. We provide them with a travel kit to help them take their meds with them. It’s a hereditary condition, so families are affected. We provide them with information kits to share with their families to take care of one another, maybe even to get undiagnosed family members to the doctor. All these things go into the big brand loyalty equation.
Ours is an IV therapy, an infusion every three or four days. We developed a program where we’ll send a nurse out to a patient’s home and show them how to self-administer the product. We pick up the costs for all that, which our competitors don’t do. Paperwork’s another issue. These are expensive biologics, so whatever you do whatever you can do to eliminate the [bureaucratic] pain to the patient, to the doctor’s office—cutting down the hassle of filling out paperwork, reducing the number of calls from the specialty pharmacies, things like that.
We’ve seen very little attrition from the patients once they have started Cinryze. That’s primarily due to the product characteristics. They’re no longer having attacks. But it’s our job to strengthen that brand loyalty by continuing to anticipate their needs, or addressing gaps. And I think that plays into the equation. It’s not the sole reason, but I think it certainly has helped us.
So if I’m a patient and I get this, let’s say, five-star service from the manufacturer, I have a higher propensity, if you will, to stay on therapy, use your brand versus going back to my doctor and doing the whole switch.
Consider someone who suffers from MS. They get a drug, and the manufacturer sends a nurse out to help him do his injections. His family helps him—they get very involved. There’s a huge online MS community, huge presence, huge knowledge sharing, very open, very candid about it. And you have websites like Patients Like Me. When you’re blogging, you’re sharing candid thoughts, stuff that could be misconstrued as adverse even reporting or trying to help someone get prescribed a specific drug. So when anyone helps the patient, they’re helping the family, and it’s very exciting.
I’d like to go back to the role of customer service in building brand loyalty. How much does customer service enter into your approach to brand loyalty—beyond, I mean, samples?
It’s big. It depends on where your product is in its lifecycle. If you have a new entrant into a new category you don’t have to provide as much customer service, because you have a great product that works. And then more entrants come in and start nipping at your heels on market share.
A couple years later, your market share may have either stagnated or decreased because new competitors come in. How do you innovate? You look to provide more service, more differentiated benefit. You want the patients to say, “You know what? This company’s going above and beyond, or this product goes above and beyond, and I then prefer it. Now I’m loyal to it.” That takes a while.
I would agree. When you get to a certain point, you have to ask, “Okay, what else do you do?” The market’s not growing; it may even be decreasing. But what is that magic level? We’re building support—not to the level in the Cinryze category, but to providing a 24/7 nurse to call if you’re having trouble using the device. Physicians love the concept. The problem is, how do we deploy it and will patients and physician really see value?
This calls for a shift in thinking. You can perceive yourself as producing products. Or you can perceive yourself as providing health solutions. It’s kind of like the government arguing about the deficit: Everybody says it’s a bad thing, but nobody knows what to do. It’s the same here: Everybody says, “Oh, the blockbuster model’s dead,” but everybody’s still operating under the blockbuster model.
It just takes a while to move. We were talking earlier about the commoditization of tactics, like the copay cards, etc.
We’re doing more things that we hope will influence loyalty in the future. We have a big adult vaccination campaign. The materials teach physicians about the importance of vaccination: physicians who treat adults are not very good at vaccination. They don’t prioritize it, because they deal with acute issues. So we’re saying, “Look, 50,000 people die of vaccine-preventable disease every year, and they’re nearly all adults. Did you know this?” Then, when physicians have bought into the need to vaccinate, they say, “Well, it’s too hard for us to do. It’s too time consuming. I can’t deal with the patient who’s always fighting my recommendations.” Then we provide lots of innovative tools and resources geared towards the top three or four barriers to vaccination. We have lots of stuff that deals with how to talk to the patient who’s combative. We’ve looked at the things that pediatricians do well: they’re really great at vaccinating. They have systems in place to be good vaccinators. Primary care and family practice doctors don’t know anything about this, so we’re teaching them about these things. We’re investing a lot. Hopefully it has an impact.
The most important thing is, if you have a good product that works, you’re able to communicate it, and you have the right position, then you’re going to have brand loyalty.
I’m skeptical about brand loyalty in most situations. I think it’s possible in those instances where patients can really see the benefit of the product, or perhaps, for example, on the vaccine side where we can help the physician out with their business. But where you can’t really demonstrate a lot of value, I think it’s difficult.
Brand loyalty is tied to functional as well as emotional benefit, even in pharma. Where you can highlight the functional differences of your brand and also the emotional component, the greater the brand loyalty you’re going to have.
It’s already been said. I’ll add that the value component and the customer service component are places we’re going in the future. I find that very intriguing, and it’s really very good for patients as well.
So, half of scripts written never make it to the pharmacy. Combine that with generic erosion curves, patients who don’t stay on for up to six months, and I think we have challenges in brand loyalty, even during the protection period. I think it makes sense for PM360 to also take a look at the business models that exist after the traditional lifecycle management curve. Once the decline starts, what do companies do? Pull resources.
I think brand loyalty will be driven by the lifecycle of the brand; we touched upon that. I think the question is what level of risk are we comfortable with. Because a lot of it is unknown. You’re doing things on your side but you’re not sure what’s going to work. We’re going to have to evolve towards customer service, away from the blockbuster model. It’s just a matter of how do we get there.
Trailblazer Brand Manager Roundtable sponsored by Opus Health, a division of Cegedim Relationship Management
Moderator, consultant, career coach, and PM360 “Common Sense”
Product Manager, Biogen-Idec (formerly Vaccines Product Manager, Pfizer).
Associate Director of Marketing,
Director, Strategy and Operations,
Manager of Communications and Marketing,
Associate Director of Marketing,
Director of the Men’s Health franchise at
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.