In part 1, I looked at
- Barriers to adherence
- How these barriers change over time (so that you can engage in stage-based RM)
- Patient attitudes toward treatment
I also wondered aloud about why marketing, brand and product managers put so much weight on the results of the small numbers of people seen in focus groups. However, I must say that focus groups, when properly run, can give you fantastic directional, qualitative information. When I went to Adderall XR focus groups, conducted with parents (largely mothers), and saw for myself mother after mother break down into tears over seeing their child labeled at school, thinking that they were a bad parent, recounting the daily ordeal over pill-taking, or even leaving a job–out of guilt–to be a full-time, stay-at-home parent.
That provided great insight into the best way to streamline the Adderall XR program from a quarterly, tchotchke-based program to a true stage-based RM program. We front-loaded the program with patient-friendly messaging about the brain science of ADHD, as well as ADHD’s “heritability”–a measure, based largely on twin studies, demonstrating the effect of heredity vs environment. For ADHD, heritability is about 80%–among the highest for any psychiatric disorder, and the same as the heritability of height in the US! In other words, from the beginning, our message is, “You’re not a bad parent. This not your fault.”
(For those of you with an interest in genetics, yes, I know that heritability is a tricky, misunderstood concept that measures only the percentage of the variation within a given population of a particular trait attributable to genes, and only within a particular environment. For example, in the US, although the heritability of height is 80%, in cultures with more variation in access to nutrition, the environment would play a much larger role in determining final height.)
This research for Adderall XR provided insights that informed a rebranding effort focusing on the child achieving his “true” inner potential, blunted by ADHD. It also was top of mind when developing branding for Daytrana, the first patch for ADHD. In these spec ads you can see that, although the patch technology is highlighted, the way in which the patch changes family dynamics was brought to the forefront. A patch avoids the daily ordeal of getting one’s child to take a pill, which is a constant reminder of his or her “difference.” And the patch is positioned, not as mere novel delivery method, but as a way to heal emotional wounds and scars.
That brings me to one more point before moving on to the next four questions that you need answered before beginning an RM program. To make RM successful, think of everything as “relationship marketing.” Broad media advertising, even though its purpose is to gain awareness and trial, is the beginning of your relationship with your patient. The same thinking that will keep patients engaged and moving through your RM program should be employed upfront–at print, broadcast, rich media, and websites.
If you’re involved in branding, bring in your RM agency: You should create and position campaigns with patient relationships in mind. In fact, “traditional” thinking is exactly backward. You should have a vision of the relationship–the engagement–you want to have with your patients. Only then should you develop adlobs and TV storyboards. What will be the tone of your relationship with patients? What will it feel like or sound like at 2 weeks, one month, two months, six months?
Especially now that the era of blockbusters appears to be giving way to smaller brands for very specific markets–even medications that require diagnostic testing to determine whether they’ll work (personalized medicine is already here!)–you need to think about relationships and conversations. The best raconteurs don’t start out by shouting or by telling you how fantastic they are; they gradually weave you into their world as you follow their narrative. Perhaps cable spots on network catering to very specific demographics, or rich media banners contextualized to the sites on which they appear, will start a conversation, inviting patients into a like-minded community. Because a conversation in a crowded bar is a lot different from one in a quiet dining room. Even the context of your first communication becomes part of your ongoing conversation.
Engagement–the new grail
Good RM agencies have been involved in engagement for a long time because, as Charlene Li and Josh Bernoff put it in Groundswell, to take advantage of social networking technologies, “you should have a vision of the kind of conversation you want with your customers.” Once you have that, you can figure out the precise social networking technologies that may (or may not) work in pharmaceutical marketing, whether you’re listening to, talking with, energizing, or embracing the groundswell.
Can pharma tap into the groundswell, with concerns around HIPAA, adverse events, and discussions of off-label uses? So far, there’s only a toe in the water, but it will be RM thinking that eventually finds the technology that makes the groundswell work for prescription medications. That’s because RM thinking begins with the question, “What sort of a conversation do I want to have with my patients?” Because the groundswell is about listening and conversing–not pushing messages. As George Glatcz, president of Vox Medica says in a discussion of engagement, “Is the path you’ve set out on going to lead you where you said you need to be ultimately?”
Listen carefully enough, and you may just find out enough about your patients to move far beyond typical DTC, beyond even direct-to-patient marketing, to “direct-from-patient” marketing–in which the needs of patients are addressed in as close to real time as possible.
Now let’s get back to the remainder of the 7 questions you need answered before you start an RM program
4. What does your persistence curve look like?
For many medications, you can almost lay persistence curves on top of one another; most show a gradual slope from the group who fill their first prescription to about 50% to 60% by month 3, gradually decreasing over time.
However, there’s a lot beneath the surface when it comes to the apparently simple term “adherence.” A recent study in the British Medical Journal reminds us that:
“Although ‘adherence’ seems a simple construct, often reduced to a percentage of prescribed doses taken, electronically compiled dosing histories reveal variably long intervals between doses and variably short durations of treatment.” (Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008;336(7653);1114-1117)
In general, when marketers say “adherence,” they really mean “persistence”–that is, whether or not patients continue to take medication over time. However, is your case one in which patients are persistent (continue to take medication over time) but non-compliant (do not take the medication as prescribed)?
Non-compliance can affect your messaging. Is it due to a desire to make refills last longer (cost issue), skipping doses (a day or two), drug holidays or “taking a break” (three or more days), or side effects?
Non-compliance can also affect the cadence and timing of your messages. For example, if you’re attempting to push out your persistence curve, there’s going to come a time at which you’re speaking to the “worried well.” But the point at which you’re communicating with this group is not so clear if you’re looking at non-compliance–such as patients taking PPIs on as-needed basis, taking statins 3 to 4 times a week, or splitting doses to make prescriptions last longer.
I’ve known many brand managers who wanted to know at what point they were communicating with the “worried well,” because they saw it as throwing good money after bad: pure lack of ROI. However, if you’re able to measure engagement factors, the so-called “worried well” could be your best advocates–they’re taking your medication regularly and they want to hear from you. You could message them differently, perhaps going heavy on “send-to-a-friend” tools and information, depending on the disease state and demographics.
Finally, don’t forget that there can be a break in adherence between the doctor’s office and the pharmacy, or even for patients who are prescribed medications in the hospital. In one recent Canadian study, patients who had had a heart attack filled only 73% of their prescriptions within one week of leaving the hospital. The number rose to 79% by 4 months of leaving the hospital. Patients filled 82% of heart-related prescriptions and only 35% of prescriptions not related to the heart (such as anti-anxiety medications). All in all, at least one in every four patients either took no medication or only some of it.
Many of these patients said that they couldn’t afford the medication or that they didn’t understand why they needed it. Here’s a perfect space where the right communications at the right time can intervene-when patients leave the doctor’s office, they need to be convinced that they need the medication. Your messaging should facilitate doctor/patient communication, complement the doctor’s advice, and explain clearly to the patient why he or she may need the medication. For example, a Q&A, ostensibly to facilitate discussion with the doctor, may never be used for that purpose, but it helps to present branded information in a more factual, straightforward–and less promotional–manner.
In other words, adherence is not a “one-size-fits-all” problem. A given solution will not be right for all drug classes, may not be right for all medications in that class, and may not be right for patients taking a particular medication.
But still, know that persistence curve like the back of your hand. In fact, imagine it as a topography with landmarks. Some of these landmarks are large obstacles, some are small hurdles–but all are potential jumping-off points where the right message will keep your patients going.
5. What are the goals of my adherence program?
The answer here should not be simply, “To keep my patients on medication longer.” Yes, that’s absolutely true, but there are different measures you can use. Choose the one most appropriate for your situation.
If you’re looking primarily at persistence, you might say that, on average, you want each patient in your database to have one more refill, or to move, for example, from an average of 2.5 to 3 refills. (However, this also involves compliance, since if patients take medication as prescribed, they will be more likely to reach their next refill sooner.)
Patient Days on Therapy (PDOT) is a number that neatly combines compliance and persistence. Your market research team can determine the average PDOT for your patient population, and your marketing team can determine the amount by which you wish to increase PDOT-or need to increase it to achieve a given ROI.
Another important and related question: Should your adherence program also be a conversion program? In other words, is your “adherence” program open only to patients currently on your medication, or do you wish to cast the net wider, making it available to those on competitive medications-and giving you a chance to build a database of handraisers who have already gone to the doctor and been diagnosed? For medications with generic competition or which require step therapy, competitive brand users in the same category may be your low-hanging fruit, because presumably they’ve already failed on a competitor, or they wouldn’t be raising their hand.
Once you’ve decided to open up your RM or patient support program beyond your own patients in the hope of achieving switches, you have a number of questions to consider:
- Do you move beyond directly competitive medications in the same class to other classes? For example, if your patients are taking ARBs for hypertension, do you also look at those taking ACE inhibitors? This seems to make sense. But what about diuretics? Patients taking diuretics could be new to the category, or they or their doctor may be concerned about cost. Will you be able to move them from a diuretic to an ARB?
- For some categories, such as allergies and acid reflux, part of your competition involves OTCs. Do you go after those taking branded OTCs? What about generic OTCs? Or even OTCs that aren’t in the same class? For example, if you’re marketing a brand-name PPI, do you reach out to those taking brand-name OTC PPIs (Prilosec and Prevacid, which is coming in 2009)? What about the generic versions of these? And what about those taking H2 inhibitors or antacids? Is it too much of a leap to get them to go to the doctor to get a prescription for your tier 2 or tier 3 brand-name PPI, especially with step therapy in the way?
- You soon cross over into market-expanding tactics, such as reaching out to undiagnosed patients who suspect they may have a particular condition. This begins to move you from conversion to acquisition. However, if you already have a program in place that discusses the disease state and your medication, and which includes useful tools and information, it may just be cost-effective. You and your marketing team have to make these decisions.
If you don’t have a goal, you won’t get there. Simple as that.
6. What messaging will accomplish my goals?
By this time, if you’ve answered the questions above, your messaging should be taking shape. However, there’s one more question not yet covered–does your medication generally require a caregiver? It could be a parent, as in ADHD, growth hormone deficiency, or other diseases of childhood; or it could be a spouse or grown child, as in Parkinson’s disease, Alzheimer’s, osteoporosis, or other diseases of the elderly. Make sure your communications involve the caregiver as well as the patient.
Develop a separate communication stream, put a caregiver section in newsletters, or develop a caregiver section of your website. Don’t overlook the important role-and influence-of the caregiver.
7. What can I offer patients, families and caregivers that they cannot find elsewhere?
This knowledge is important–it informs your messaging, and without unique content or tools, even the right messaging will only take you so far. With approximately 60% of people using the internet to search for health-related information, but only 10% to 15% going to product.com sites, what can you offer that they cannot find elsewhere? Because you can be assured that, right now, there is a conversation taking place about your medication, and you want to be right in the thick of it.
What reason can you give patients and caregivers to come to your site? Why should they register for and read your newsletter? Do you even want registration? It greatly suppresses use of a site, but that may be okay. You and your marketing team have to decide the optimal trade-off between number of visitors and amount of information gathered. Can you let everyone in and generate registration with offers of loyalty/discount cards or certain unique tools accessible only to registrants? Or do you require registration upfront?
For Stepping Stones, a registration-only site for patients taking Nutropin (a growth hormone), we offered an interactive tool that plotted height over time. All the caregiver has to do is key in the date and height, and a chart is created. That chart contains “growth channels” (height deciles for age) that show whether your child is staying on track (generally, sudden moves up or down are a cause for concern). We wanted only caregivers and patients taking Nutropin, and we signed up thousands in record time. We also offered information about the five indications that was not easily accessible elsewhere, generating patient-friendly content from the medical literature and conversations with our client’s on-staff doctors and nurses.
For Azilect, we offered interviews with key opinion leaders, including leading neuroscientists and clinical experts, all on the cutting edge of research into Parkinson’s disease. We also offered the perspectives of fascinating people living with Parkinson’s disease, both caregivers and patients.
Thinking of fresh content is especially important in disease states that already have advocacy associated with them–think of diabetes, for example. What can you provide that is not readily available at the American Diabetes Association or through the NIH?
Think of your RM program like a true branded product. What are its unique features? What are its benefits? How does the relative emphasis change for different segments or for different indications? What is your RM program’s reason for being? Answer these questions, and find the right messaging for your audience segments, and you’re well on the way to building an engaging, successful multi-touch, multi-channel RM program.
