In last month’s edition of the DTC Perspectives’ DTC in Focus newsletter, we discussed patient engagement and provided prescriptive thoughts on maintaining and even increasing patient commitment. This month, we take that thought one-step further (as well as, adhere to this month’s theme) and focus on patient adherence. The discussion includes whether the emphasis of such programs should be on both long and short-term medication adherence particularly in how they are resourced and measured.
A situational review
Current support programs typically devote a large amount of time and money ensuring patients initiate therapy. However, these programs never allocate time or funding to safeguard that the patient maintains adherence after that time period.
Studies indicate that patients with chronic diseases may not either grasp the severity of their condition; understand the literature they receive about their condition; or require multifaceted efforts to achieve adherence.
Current support programs operate in silos. While these programs are typically mapped out strategically, they are not executed in a coordinated fashion.
These silos execute patient adherence programs:
Co-pay card company
Reimbursement and benefits investigation vendor
Consumers, patients, and caregivers often are not satisfied with the content and creative contained in patient adherence programs
These targets at some point in the treatment process stop at Brand.com. All find the information initially helpful, but tend to look somewhere else for information because the information they want or need is not in the adherence program.
Patient adherence programs today are like an inverted hourglass. The strategy is thin at the top, disparate and expansive in the middle due to the silo construct, and then the program strategy attempts to narrow again. Yet, often this does not occur.
While all pharma brands say they have patient adherence programs, the reality is – and I am basing this information on my 20 years of experience – very few deeply engage and build a relationship with the patient; maybe 10% to 15% really execute this well. These programs work because senior leadership is committed to them for the long term, both in human and financial capital. (See last month’s column re: Biogen Idec.)
Operational issues still exist today
Along with the barriers already mentioned to pharma’s delivering quality adherence programs, there are two more barriers, and they are formidable.
First, product managers are no longer brand champions. Their roles now resemble those of purchasing procurement agents who buy a single program; their sole hope is to get noticed by senior leaders.
The second, arguably more significant complication is the FDA, namely its regulations. Companies have allowed their legal and regulatory teams to make business decisions regarding programs that minimize risk in terms of providing the evidence and content that patients and healthcare professionals want. The pejorative natures of today’s drug marketing regulations are designed to educate, not inform. Grant Corbett, a psychologist we have worked with says pharma produces content from the perspective that patients and others affected by disease are not competent to understand the information so brand programs need to “educate them.” He asserts companies should make the opposite assumption and assume the patient, caregiver and consumer understand their condition and work to provide information that fills in the knowledge gaps. This is where great programs in the marketplace are focusing their efforts today.
Answers exist today
The short-term lead generation and conversion marketing strategies of patient adherence programs are no longer viable. The key to winning at the ground level is to have the program’s patient advocate be part of the solution that has been prescribed. It is paramount to ground a multi-channeled adherence program in a scientifically validated model to instill confidence in patient and caregiver. Patients and their care team need to believe they have the complete and long-term support needed to overcome their disease. Moreover, to accomplish this, the program needs resource and execution in a coordinated fashion. These are the factors creating a real competitive advantage in adherence programs today!
While industry spends $10s of millions on various aspects of the entire effort, that resource is cut up into smaller chunks or pools of money. This causes all parties to fight for their chunk of the pie and to lose interest with the whole strategy. Senior leaders, in this age of consolidation of resources, must consider these programs at a total cost level and ensure they all are driving value. That is why we advocate bringing back the role of a Brand Champion, an individual or set of individuals who commit to a longer-term career path with the brand, who can oversee the convergence and collapse of the silos – and decide how to spend the money.
Finally, we are big proponents of the net promoter score construct. Two or three simple questions added to any program to assess the patient’s willingness to recommend a product to a family member or friend. This simple measure helps leadership teams stay focused on the end goal of customer satisfaction, regardless of the program’s timeframe.
We know that the formation of healthy lifestyle habits is critical to overall health. However, adherence to exercise programs, medication regimens, or dietary changes can be challenging. So how do we help patients develop habits to improve their overall health?
Habits are defined actions employed without conscious thought.1 Habit forming potential of any behavior is often driven by two factors: frequency and perceived utility. The more frequently a new behavior occurs, especially within a short period of time, the stronger the habit becomes. Likewise, the more rewarding the behavior is perceived to be (its utility), the greater the chance for habit formation. The “Hook Model” is one method that we use at Health Union to build value and encourage habit-forming behaviors within our communities. Four key components converge in the hook model – a trigger, an action, a reward, and an investment2 – to create ecosystems that cultivate engagement habits and motivate people to live better with their health conditions.
Health Union communities use both internal and external triggers to encourage patient engagement. External triggers may include advertisements or comments from doctors, family, and friends; while internal triggers are leveraged when an action becomes strongly tied to a thought, emotion or preexisting routine, like checking email every morning. While we utilize some paid external triggers, like Facebook advertising, we’ve found that relationship triggers (social media sharing/word of mouth) and owned triggers (opting into a weekly newsletter) are most effective for long-term engagement. Owned triggers are most likely to prompt repeat engagement until a habit is formed, and relationship triggers support continuous community growth.
The more people interact with your product, the more likely they are to keep doing it. Our community engagement strategy creates a “funnel” approach to increase the level of participation over time, knowing that simple actions can lead to big changes in future behavior.3 For instance, our members may start as site visitors, then progress to following us on social media and engage in passive activities like anonymous polls. Passive participation may lead to newsletter registration and eventually active engagement by posting comments or personal stories. It’s important to make it easy for even the most passive patients to engage while still providing outlets for the most active members.
Provide a real benefit to action – with variability – and do it quickly! Show people that taking action results in a clear benefit. Of course, keep in mind that the preferred benefits vary from one person to the next. Make sure to clearly communicate what the reward is – whether that is answers to basic questions, immediate poll results upon voting, published results from surveys, or community support. Don’t assume the reward is obvious and communicate the benefit gained by others as well as that of the individual. Variability can multiply the natural effects of a reward and keep people coming back for more. All Health Union communities provide daily content that is relevant and useful, but the type of content, topics, and authors are varied to create novelty.
Encourage people to make an investment, beyond just lurking or passively clicking. This may be an emotional investment, an investment of time, or a contribution of personal information. Investment implies action that will improve the service for the next visit. And, the greater the investment, the more likely they are to continue engaging over time, thereby increasing the value of the product. For example, the simplest investment is to follow one of our social media accounts. However, we also invite members to “own” part of the site by participating in surveys and publishing personal stories.
What else can we do?
In addition to the four elements of the Hook Model, don’t forget to …
Remove barriers and provide support. Be aware of both perceived and actual barriers. For example, in response to a perceived barrier that weight loss is dependent on foregoing all desserts, provide recipes for healthier dessert options.
Strengthen self-efficacy, the belief in one’s own ability to complete tasks and reach goals. Since many people are uncomfortable asking their doctors questions, provide discussion guides to encourage dialogue focusing on areas where the patient is the expert – like how a condition affects day-to-day life.
Find what people are doing already, and make it easier for them by linking habits to daily routines.4 Our content strategy focuses heavily on giving people the information we know they are seeking, where they are already seeking it (with social media and search).
The ultimate goal is to create a cycle of interaction where the investment itself becomes an internal trigger. Members seek responses to topics discussed within the community – that desire for shared experience is the trigger to continue engaging. And then, they’re hooked!
E. Morsella, J.A. Bargh, P.M. Gollwitzer, eds., Oxford Handbook of Human Action (New York: Oxford University Press, 2008).
Eyal, Nir. Hooked: How to Build Habit-Forming Products.
J.L. Freedman and S.C. Fraser, “Compliance Without Pressure: The Foot-in-the-door Technique.” Journal of Personality and Social Psychology 4, no. 2 (1966) 196-202.
Bas Verplanken and Wendy Wood, “Interventions to Break and Create Consumer Habits, Journal of Public Policy & Marketing 25, no. 1 (March 2006): 90-103, doi: 10.1509/jppm.25.1.90.
After a patient initiates treatment, the real selling-process begins. More than ever, patients are approaching Rx-trialing with a heavy dose of skepticism. It’s understandable. Oftentimes, long-term treatment is thrust upon patients without time to get comfortable. And sometimes, those patients have healthy fears over side effects. On the other side of the coin, many patients expect treatment to fix everything fast or they diminish the value of Rx treatment altogether (before giving it a real chance).
This net skepticism has fueled – no, skyrocketed – a behavior patients hold dear when trialing treatment. And that is finding the authentic truth – conducting their own in-depth exploratory research into Rx treatment expectations, outside of brand communications. Outside of the brand context is where patients perceive to find this authentic truth and the optimal basis for their own opinions and behaviors toward Rx treatment.
Here, I’ll explore this rising phenomenon a bit more and then present an opportunity for brand adherence communications. Essentially, I’ll show you how to guide patients toward external content, in order to help them find their own, preferred version of the truth. In the end, they want to put the “authentic” puzzle pieces together. If we can help them do that, we can help them feel more comfortable with treatment early on and more receptive to the rewarding possibilities of long-term treatment.
Origins of the truth
A year or so ago, I spent time reflecting on the success of online services such as Angie’s List, Yelp, and others, with large investments into customer review networks. I came to one conclusion: in the digital age, the truth comes from strangers.
My hope is that this speaks to you, as both logically flawed and intuitively accurate. Let me explain. Logically speaking, we put our trust in people/entities we know, or in some cases, those we think we know. In this case, the ol’ saying “never trust a stranger” holds true. But today, we live in a hyper-consumerized world where we have many “long-term relationships” with an array of organizations and companies we really “know” little about (e.g., mobile phone, streaming, cable, grocery delivery, etc.). We expect those companies to meet our expectations or, in other words, be trustworthy.
In many cases, the results have been less than stellar. However, there are exceptions. Brands like Zappos and Wayfair have elevated the benchmark of customer service to a religion – but again, these are exceptions. And, the fault cannot be placed entirely on either side – it’s a combination of consumers and companies. Consumers can exaggerate or even create the problems, yet companies (or brands) aren’t exactly model citizens, when the almighty dollar rules the day.
Regardless of who’s right and who’s wrong, the net result has been a heightened mistrust among consumers. You could even say it’s already hit the boiling point with persistent steam ahead. Who can we trust these days?
The person/entity we often trust is the person/entity with no vested interest in us: the stranger. They don’t want our money, our commitment, or a relationship. They do have opinions, though – invaluable ones about the subjects that matter most to us. And they like to voice these opinions. It’s these anonymous voices we seek in order to find the authentic truth and, as a result, make better decisions.
The patient “truth-seeking” journey
This is the kind of approach patients take when trialing Rx treatment. They get the doctor’s version of the story, they get the brand version (e.g., brochure, site), and then they go looking for the outsider context: the anonymous opinion, the unknown academic perspective, the clinical trial data, the virtuous community site, and even sponsored content, but on a trusted site.
Now, let’s bring these learnings back to the question at hand: how can Rx brands become an integral part of the content system patients tap into when finding their authentic truth?
First, I have to acknowledge that this is not a one-stop shopping experience for patients. They will leverage this behavior at multiple points during treatment. In my experience, the best way to manage this is to glean the most important barriers to short-term, intermediate, and long-term adherence. Typically, short-term issues surround potential side effects, whereas intermediate and long-term issues usually surround side effect experiences, efficacy, and cost.
On the subject of cost, we often think of cost-saving programs benefitting patients just starting treatment. What I’ve learned is that most patients wrestle with treatment value relative to cost, once they’ve come to the conclusion that they’ve experienced said treatment’s full potential. For the commercially insured, if their treatment co-pay is negligible (through a branded support program), they will likely accept average efficacy, for example, and stay on treatment longer.
So, how do we use branded content to encourage adherence, while embracing a patient’s journey to find the authentic truth? Below are five recommendations to help you, and your patients, succeed:
Use a trustworthy environment to evolve your brand marketing into brand truth.
Market clinical studies without feeling like your marketing clinical studies.
Gain their trust by setting them free.
Let patients – even help them – find the good and bad about your brand.
Lastly, recognize how search can unearth issues patients were never searching for.
Patients hold all the power these days. Let’s help them realize that dream… and get rewarded for it.
EDITOR’S NOTE: This is a condensed version of John’s article. To read the full-length feature and learn more about the five recommendations for the authentic truth, check out his upcoming article in the 2015 annual issue of DTC Perspectives Magazine out next month.
About the Author: John Nelson has spent over 13 years in advertising, working with some of the most iconic health brands of our time. In his role as VP, Strategic Planning at Evoke Health New York, John is responsible for inspiring strategy that creates big ideas and big connections between brands and people – connections that drive behavior change and deliver tangible results for clients. He can be reached at firstname.lastname@example.org.
As the new model of healthcare delivery takes shape, the spending burden for care continues to shift to the patient, giving them more control over their care. As a result, patients are more informed and have access to more healthcare decision-making tools than ever before.
However, it needs to be relevant to them. Recent research commissioned by McKesson shows that patients are less interested in general information about their condition and more interested in personal communications and support in the form of missed prescription reminders (89%), refill reminders (87%), live phone support (86%), and pharmacist coaching (83%).
Evolution of relationship marketing
In the past, one size-fits-all-messaging followed by content delivered through traditional communication channels such as e-mail or print, enabled brands to deliver consistent and controlled messages to the patient. However, this model did not enable dynamic two-way communication, where questions can be asked of the patient, responses captured, and then messaging and actions tailored accordingly. As a result, the ability to create lasting behavioral changes was limited.
Driven, in part, by more engaged and empowered patients, new technologies now enable brands to perform more targeted outreach to patients with specific medical conditions, on particular medications, who have opted in to receive information. While this improves patient targeting and personalization of the message, this evolution of relationship marketing in healthcare is not just about pushing a brand message, but about creating greater patient engagement and opening the door for two-way conversations designed to improve adherence and outcomes. Ultimately, this support helps to differentiate the brand from its competition, driving adoption and adherence.
Delivering personalized support
There is no silver bullet for impacting adherence as every patient is diverse and every patient situation is different. Complexities that can impact a patient’s likelihood to remain adherent include the length of time since diagnosis, brand challenges and attributes, cost barriers often outside the patient’s control, and the nature of the diagnosis itself.
The ability to uncover what behavioral barriers can be modified and to recognize what factors cannot be changed (e.g., doctor’s choice to discontinue the medication), is one of the benefits of dynamic live patient interactions. While each patient’s individual situation may be unique, our experience in behavioral coaching reveals that there are similarities across therapeutic conditions which can be used to infer best practices in addressing patient challenges across brands and patient populations. For example, sensitive conditions (HIV, Hepatitis C) have social implications that require more empathetic messaging than more mainstream chronic conditions, such as Diabetes or Hypertension. Patients with a visible dermatological condition (psoriasis, onychomycosis) often face quality of life issues that physicians may not fully embrace and will need significantly different support.
Recognizing that adherence barriers change over time, as well as patients’ information and education needs, brands can integrate out-bound support and multi-channel communications to maintain that personalized support for patients throughout their brand journey. In this scenario, delivering smarter dynamic communications can help connect patients to support driving brand loyalty and program success.
Consider a program that helps patients navigate their own healthcare decisions, supporting adherence, sharing information, addressing barriers along the way and deploying proven behavioral-based techniques. One example is McKesson’s Behavioral Call Campaigns (BCCs), which use live agent support to identify adherence barriers and provide targeted messaging to help overcome those barriers, connecting with patients using proven health behavior change tools and techniques to build programs that allow patients to opt in to allow them to be more engaged in their healthcare decision-making, while aligning personalized messaging with a patient’s intended utilization activity. These campaigns can be used as stand-alone solutions or integrated into broader marketing campaigns by pairing them with financial assistance or educational support programs.
Engaging live interactions
Successfully tackling adherence requires a comprehensive strategy that includes multiple communication channels to support patients towards positive behavioral outcomes. Coupling in-bound and out-bound support, live patient conversations can transform static traditional relationship marketing programs and allow live agents to uncover patient needs over time and use behavioral coaching techniques to address those needs. Pharma brands are increasingly leveraging live support, the insightful data provided through their co-pay programs, and segmentation tools to help predict a patient’s level of engagement or likelihood of being non-adherent, then allocating the investment accordingly.
Brands using these tools at enrollment can segment patients in order to provide additional support only to patient segments which need it. The interesting brand question then becomes which segment should you invest in: the group that you predict will be adherent and most engaged; the group you predict will not be adherent; or the group in the middle that could go either way?
This is a great conversation to have with your contact center strategist.
How do we keep patients adherent? It’s the billion-dollar question in the healthcare industry. And the truth of the matter is there isn’t one simple answer.
In the past year alone, nearly 75% of adults age 40 and older with a chronic condition admit to not adhering to their prescription medication treatment. As healthcare marketers, we focus our efforts on getting patients to the doctor. We’re hoping to motivate them to make an appointment. We provide tools and information to talk to their doctor about medication. We encourage them to ask for a particular brand by name. We push the HCPs to prescribe it. And finally, we hope that patients fill it and actually take the medications as prescribed. It’s a significant investment – time and money. Yet, after all of these efforts, only 25% of these patients are taking that medication as directed. It’s apparent; we have some work to do.
So, what do we do? Often I hear healthcare marketers telling me they are focused on driving adherence through a particular tactic. “We’re
going to invest in our CRM database” or “We’re using text message reminders” or “We’re utilizing SEO to keep our brand top of mind”. Good! These are great tactics. But by merely implementing a tactic, you’re checking a box to say you’re driving adherence. Is that enough?
We need to be better and smarter about how we are keeping patients adherent (remember only 25% of patients are adherent). We cannot only be thinking tactics. The reality is, keeping a patient adherent requires much, much more. To keep a patient adherent to their treatment, we need to be their partner and support them, and also look at the key motivators in a patient’s life: spouse, parent, child, sibling, boss, friend, HCP, and many more. And who is their biggest personal motivator? It is their spouse or partner as shown a recent study conducted by Remedy Health Media with Princeton Survey Research Associates International (PSRAI). (See related pie chart.) When it comes to healthcare, we rely on the people we are closest to, our support systems, and the people we trust. It truly takes a village to motivate a patient to stay adherent and committed to their health.
My personal story 10 years ago my husband complained that he had terrible heartburn. It was a daily battle. He attributed it to too much eating and too much drinking (at 25 years old, I’m sure that was the case). But then I explained, although it felt like a daily discomfort, heartburn/GERD can have long lasting and damaging effects. I urged him to see a doctor. After he reluctantly made an appointment, to be supportive, I printed out 10 questions for him to ask his doctor, along with a medication to request. At the time, I’m sure he thought I was slightly annoying with my persistence and I am certain there was some eye rolling when I handed him the printouts… but he took them. Then after a productive and successful doctor visit, he was given a prescription, and he’s been taking the same medication ever since. Even today, to keep him adherent, I ask, “Did you take your pill today?” Although it’s his health, I’m a part of it, I’m connected, I’m supportive. I feel responsible.
We are responsible for our own health, and we also feel responsible for somebody else. It’s what connects us. It relates us. We rely on each other. Health is incredibly emotional. It’s happy, it’s sad, it’s scary, it’s confused, and it’s triumphant. It is real. We’re an industry dedicated to helping people live better, healthier lives – yet we get bogged down in the tactical solutions rather than the big idea of how we can create change and embrace patients. I challenge you to put down your excel spreadsheet. Look beyond the media spheres of TV, print, digital, mobile/tablet, etc. Stop for a minute. Take a step back. Be human and put a relatable, personal approach to adherence. Challenge yourself to inspire millions of people. It takes a village. But we will get there.
The goal of any support program should answer this question: What factors must we use in the program that will instill patient confidence in our product – and by default our company? Trust is built by a series of actions and those actions speak volumes more than any words or discount prices ever can! A recent article in eMarketer reported seniors do not trust pharmaceutical company sites and prefer WebMD more. In this work, companies need to be brave and work harder to deliver a better “patient experience,” while a patient is “on the product.”
A situational review
Patients do not want a relationship with a product; they want an “experience.”
Federal regulations tend to inhibit innovation in these pharmaceutical support programs.
The pharma industry’s patient support programs, in terms of the information they provide, are not valued as they once were. So many other avenues are available, and considered more trustworthy, to patients to get information, including the Internet and patient advocate groups. Maybe it is time to give Regulatory and the other legal protectors some new assignments.
Competitive pricing could force excellent programs to be marginalized and undifferentiated (i.e. Gilead and Abbvie in hepatitis C).
Patient Engagement is the hot new topic. Not only is pharma trying to come up with a viable, profitable formula for PE, but the Accountable Care Act is forcing many ACOs, integrated delivery networks, and other health care delivery system to tackle this issue as well. With so many different health care systems putting their unique spin to the issue, other questions arise: what works, what does not, how to separate the good from the bad? Think mobile app development.
The industry has examples of good and bad pilots. When programs scale to larger patient populations, they lose their patient focus. Outside of specialty drugs, physicians will choose DTC efforts over patient support programs as a factor influencing prescription recommendations.
The first problem is inherent in the program itself: Not all are ground in proven theoretical based methodologies that assist with a patient’s needs. In our opinion, the way to connect and engage is remove the current program silos. Commercial organizations need to consolidate approaches, converge vendors, look to execute more than innovate, and, most importantly, measure and value engagement as much as they do reach and lead generation efforts. Senior leadership should consider looking at the total spend as many fail to ask if all those dollars being spent can be focused more effectively to deliver better program execution.
It has been done before
We frequently mention the work! Biogen Idec demonstrated this with its MS drugs (Avonex & Tysabri) in the in the late 90’s to early 2000’s. Its focus was execution excellence and customer support. The call center and customer relationship management approach acted as the quarterback of its patient focused efforts. Its current website says it handles 800,000 calls a year.
Patients wanted to know about what to expect on therapy, they wanted to know what side effects they would experience, especially with Tysbari’s known side effect, Progressive Multifocal Leukoencephalopathy ( PML). Because of the regulatory requirements, the company embraced this as an opportunity, not a burden, to disclose potential side effects. Moreover, in 2002, Biogen had to take these issues head on because of other products in the market and the high visible media reports on PML.
Back then, management felt it important to have an employee assigned to each patient or caregiver as the single point of contact and relationship steward. This required consolidation and coordination with the ad agency, PAP, HUB, Co-Pay Card, Reimbursement and Benefits investigation, specialty pharmacy and technology.
It’s not a stretch to say that, 13 years later, this plan is still literally paying off: To quote a recent Motley Fool: “Biogen Idec’s MS drugs include the billion-dollar blockbuster drugs Avonex, Tysabri, and Tecfidera, as well as the company’s newly launched Plegridy … Sales of Biogen Idec’s MS drugs increased 47% to $7.93 billion, and its total sales increased 40% to $9.7 billion last year.”
In conclusion, keep in mind these points:
Doing this right with patients will produce the brand’s best product advocates.
Switch the metric quantified! Measure and reward commercial and medical teams on the number of patients who get better on the therapy as a result of the product and support; not on how many new patient starts were achieved in the past week. Measure engagement, get engagement is what produces real results!
“What have you done to help a patient on our product today?” should be stuck on a post-it on every employee’s computer, laptop and iPad.
If the product works, produces outcomes, and patients can easily access information they want, this will help them. They will get started on therapy and realize the value of staying on therapy for the long term. Consider who saved Tysabri from a market recall.