Download - Where Does DTC Go From Here?

“Don’t Worry, Be Happy—”Where Does DTC Go

From Here?

Laurie Gelb, MPH

The views expressed in this presentation do not represent the views of any other person,

company or industry organization.

This deck is an update of a presentation to Defined Care 2004, sponsored by Managed

Care On Line.The author is now

Principal, Profit by Change

Healthcare background Hospital PBX, lobby receptionist, admitting rep

Researched patient, nurse, AHP, physician satisfaction and developed market-driven strategy for Texas hospital/health system clients

Managed MD Anderson’s Biomathematics department

Moved into rx, with vendors, then in biotech, then in big pharma; later in managed care (outcomes research)

Publish/present on e-marketing, decision models; blog at Managed Care On Line and examiner.com

Rx/OTC/ACM is unique

“Feeling good” or “feeling better—” when do needs differ from wants?

Housing

Food

Warm clothing

Acute rx/tx

Entertainment

Leisure travel

Home electronics

Fashion clothing

Upscale housing

Higher education

Employment

LuxurySurvival need

Means to end

Self-contained

Massage therapy? Allergy meds?

Definitions The “right” treatment is …[your definition here,

incorporating clinical efficacy, safety, cost, logistics, compliance/persistency]

The “right way” to take rx is following label cautions, incorporating other modalities for maximum benefit, dosing consistently, etc.

The “right” patient is s/he for whom a drug is indicated

The “right” time is as soon as the drug will achieve significant benefit

Our goal: the “right” synergy

We want the right patient to take the right drug at the righttime, the right way, for the right reason, and thereby

address a medical need

We’re lonely at the top, because the stakes are high

Resentment

Ignorance

PovertyDenialFear

External sources daily assert:

Evil drug companies are withholding lifesaving drugs from the poor and elderly here and in the Third World, wasting millions in marketing to the insured

As a wealthy society, we use rx to improve mood, allergies, sex lives, etc. when we should be attacking “root causes” through “natural healing/prevention,” less conflict, less pollution, etc.

You should take as few drugs as possible, except for…

Generalizations are tempting

Thinking about rx means…

When you see “Mr. Clean” in someone’s kitchen, there is a “wink-wink” component of humor and exaggeration

Is that tone appropriate to DTC? Does it facilitate rational decision-making?

HCPs, payors and biopharma all have a stake in conveying that pills are not commodities – that the rx decision is a serious one

A possible failure to communicate the right…tone?

Fear & loathing in the headlines, risking suboptimal decisions

Drugs can heal, disable and/or kill

Nor is the ultimate position on the pleasure/pain continuum as predictable as with other goods

The specific drug as benefactor spurs antipathy and resentment – who wants to have to think about, take or depend on rx?

The consumer can at once fear, live with and cherish:

The drug itself; having to consider it at all

What the drug does

What the drug doesn’t do

Not knowing what benefits/risks will actually apply

No rx guarantees, so attachment’s always conditional

“I’m not as energetic/happy as I should be” [expectation gap]

“I feel pain/weakness/fuzzy/numb” [active concern]

“My doc says I weigh too much/have high blood pressure/have diabetes” [physician’s attribution]

“My boss says I look tired all the time” [peer observation]

“I had chest pain when I played football with my son last week” [isolated event]

“I just want to stay healthy as long as possible” [goal-setting]

“My aunt died last week and she was only 61” [benchmarking]

Contexts breed expectations

Understand how DTC/DTP exposures affect consumers, with every word

“Freeze frame” methodologies – stop and reflect

Explore real-world mediators of calls to action, not just likelihood scales

Probe how problems perceived; with whom discussed; recommendations made; never presume that DTC exposures are even processed

Explore the duality of rx

Allow consumer/patient to want to take responsibility because now s/he understands how, and to make rational decisions

Never stop reinforcing the rx decision’s importance to the patient

The more conscious decision-making, the happier we will all be; decisions based on emotion may not last

When/why does the right thing seem right?

Consider the contexts

The capsule has two faces See drug exteriors; inside is mystery Endless reading, but rarely discussions Hear drugs are risky/not; trivial/not; the cost of modern

living/the bane of civilization… Most patients charged considerably less than “retail”

but often believe they overpaid May take drugs daily, feeling insecure every time Seldom is the consumer’s objective to “buy more rx,”

(this is not “got milk®?”) but besieged by messages pointing to specific drugs and disorders

Rx: seldom “wanted” in the abstract

The consumer: I want this only because I need it—(we do not generally “follow the rx leader”)

We seldom ponder whether to want the benefits from a prescription drug, as opposed to a DVD player But may ask if we really “need” a drug, an opportunity to ensure

that the right hands are reaching for the right benefits HCP: What you need is… Marketers: You should want our class/brand (since you need it) Counterproductive to convey that some rx decisions should be

easy, no-fault and others not

Rx access entails multiple costs, e.g. financial, emotional and opportunity costs for care-seeking, transactions, reimbursement

Layered on concerns about professionals, processes and payors

“My physician just wanted to get me out the door, so he wrote me this prescription—” [is there a better but slower option?]

“My insurance company sends me letters about ‘disease management,’ and I’m not even sure if the drugs I’m on are the right ones” [should I be re-evaluated]

“The pharmacist asked if I had any questions. I have a lot, but I don’t know who should be answering them” [I’m not yet fully satisfied with the decision(s) I made]

Rx access costs more than money

A drug can be personalized: “I can’t sleep without my pills” and we warn consumers not to share rx

Yet formularies, generics, Internet pharmacies, re-importation and pricing debates/magazine spreads imply drugs are interchangeable commodities

As those in need beg, borrow and steal drug from the living and dead

The same molecule can be a veterinary or human formulation, with a different route of admin/ color/shape, and priced differently by channel

Physical product generally loses value over time, but investment may gain value, e.g. years of controlled vs. uncontrolled dz

How personal an investment is rx?

Knowledge actual control, but can increase perceived control

Survey analysts frequently confuse needs for control and knowledge with attitudes. Some consumers may assume the worst, rather than relinquish perceived control

Knowledge

Intervention

Decisions

Health decisions are continually re-evaluated, entailing changes in modalities as well as rx

“My drugs keep me in balance. They give me control over how I feel.” [severely ill pt]

Control

When does realism fatalism?

Mike Twohy, New Yorker, 6/10/2002

Consumers don’t necessarily want all the ramifications, but they…

Often can’t presume that health care players have only their interests at heart

Assume personal responsibility to the extent of clear benefits, though still reluctant to believe that: Health is a direct function of money spent Unwise spending can endanger health

Want to believe that if drug companies are working with HCPs/payors, it’s for their own good, though increasingly afraid that it’s not

You may have a problem [can be oblique, e.g. ED]

You <can/deserve> to feel better, address the issue and/or lower your risk

This drug can help you achieve the above

Ergo, you should take this drug, presuming you have this problem

You can do other things to help yourself, too

Issues:

Same source identifies problem and how to fix it, yet the drug itself is not responsible for treatment/care of problem (push/pull)

Discussion of the “down side” or alternatives may be sandwiched between emotional appeals, like many sales messages

You may have a problem, but there’s a solution

You may have a problem, like the person depicted

Ergo, if treatment’s right for you, you may have the option to undertake it in consultation with your physician

If you choose rx treatment and have this problem, you’re likely to achieve certain benefits…

Barriers:

More sophisticated than the value proposition for ice cream and odds of predictability, success vary [product and benefit not as tightly linked]

Limited availability of clear, concise, reputable information on alternatives

User may or may not re-evaluate decision that may not have been made rationally to begin with

We can make the right thing seem more right

Method in the message:

How can DTP inform the re-evaluation process?

When will I feel better? If I split it in half so it will last longer, will it still do me any good? What if I forget to take this twice a day? How do I know if it’s not working? Should I expect my symptoms to go away completely? Will this interact with anything else I consume? If I don’t take this, what will happen? Could this make me worse? Has something better come along since I started taking this? Have known risks changed since I began this?

The issue is not “good vs. bad rx” but when, why, where, what and how it’s a good decision to take rx

Consumers neither want or need to be sold on health care or drugs as products on a shelf or in vitro

They want to know if an option is appropriate for them, irrespective of labeling or others’ experiences

Does “ask your doctor if [drug] is right for you” sufficiently draw this distinction?

Does a brochure in the waiting room link the drug to the exam room?

a leap of faith into a decision

(Still) Taking rx is…

The drug that “works fine” suddenly causes an AE

The fill that is easily accessible for $15 one year is grudgingly supplied for $50 the next

The physician who wrote a script a month ago now says “You shouldn’t be taking this long term -- we want to get you off this”

Entire classes, e.g. statins, are described as wonder drugs one day and potential killers the next

Meanwhile, the “Looks Can be Deceiving” campaign and other interventions communicate that all rx is not equal

sometimes, having to think you’re sorry

Taking rx is…

OTC, device, ACM and supplement providers tout more “healthy,” “natural” alternatives, many “without drugs”

With some options effective and many not; many resting on placebo effects and energy/mood synergies

“Health position” encourages CDH and HSA/HRA or FSA enrollees who can trade costs against rx to do so

Rx cannot afford to be niched as either the first or last resort

DTC often appeals to the health/pleasure position, a la the first resort; but, unlike chocolate, rx is not positioned there

Especially when plans’ preventive or “controllable” rx lists differ from consumers’

more than a single decision

Taking rx is…

7 am: Take new drug, trying not to notice the “do not take with alcohol” sticker, since you chased last night’s dose with your usual glass of wine before bed

8 am: See TV commercial for your new drug; the theme is “everything you need to be”

Noon: Lunching with a friend, you mention the new drug. “Why are you taking that?” she asks incredulously. “I thought you didn’t like drugs.”

4 pm: Feeling slightly dizzy, you call your doctor’s office, not sure if you’re hung over or reacting to the drug. The nurse advises, “call back if you’re not better in a few days”

Taking rx: a day of competing cues

I don’t feel like taking my antibiotic today; my stomach’s upset

I can’t get by the drug store till Saturday – if I still have a fever then, I’ll get the prescription

I’m in a lot of pain – I’ll take two of these

There’s a long line at the pharmacy counter – I’ll come back later

My mother-in-law has something she says works better

If I list out all the supplements I take, I’ll sound like a health nut

I don’t want the doctor on call – these worked last time and I’ve got some extra

Rx cusps: when internalized messages are key

Deciding to take any drug, vitamin, mineral or herb (OTC, rx) is a serious decision with potentially grave consequences

People are different, so the best option for you may not be best for someone else, and vice versa

The labels or package information included with drugs should be taken literally unless an HCP directs otherwise

Your HCP is best equipped to advise you about treatment options

– Knowing all the substances other than food that you take, whether prescription or not, is essential to providing you with the best advice

Your medical situation and the treatments available change, so you may need to change medications or therapies from time to time

Rx cusps: what messages should be internalized?

Fatalism’s easy when dinner’s now the villain…

Michael Ramirez

Not for fatalists, defined care says: You determine what you pay for drugs

Decline any script not in your best interest, and don’t request unnecessary rx

Ask about alternatives to expensive drugs It’s time to manage your own pharmacy budget and you can do it!

(Self-efficacy message)

Given personal responsibility without offering total control (e.g. some rx is treated differently), control can become a burden rather than an opportunity Leading to both opt-outs and obsession

The “natural course” of many diseases ends in disability and/or a painful death

If “natural healing” were not severely limited in efficacy and safety, drugs would never have been developed

Naturally-occurring beneficial chemicals are often less and more variably potent than their synthetic analogs

Obesity, neuroticism and other consequences of a wealthy society are generally helped, not caused by drugs

Interfering with “nature” often improves/extends life

Points to make

You are most likely to improve your health by taking a prescribed [not prescription] medication, with a less certain outcome if you do something else instead

Adding another health regimen to your drugs often produces even greater benefit, whereas unhealthy behaviors can cancel out drugs or make them dangerous

So, your ability to change your health neither begins nor ends with filling a script

Health, not days on drug, is the final goal

Even with rx on board, you’re still the driver

Points to make

What’s powerful enough to help your heart work better, or lower your blood sugar, or reduce your tumor, still needs you

A pen is nothing until you write with it. A shirt cannot keep you warm until you put it on.

A drug best addresses your needs when you use it as directed, monitor your progress as needed, report side effects and/or lack of efficacy, and refill it before you run out

Though some drug classes have intrinsically greater potential effects on your lifespan than others, a decision to take either should be informed, rational and re-evaluated as needed

With great power comes some responsibility

Points to make

Whenever we reduce consumers to summary statistics derived from claims databases and surveys, we lose sight of their varied, individual decision contexts, issues and thresholds

Use primary research, including direct observation; validate claims data to zoom in on the qualitative rubric of rx drug use: ACM, OTC, re-using meds, splitting, skipping, hit & miss, etc.

When/why do consumers think and then act; when/why do they think but not act?

What thresholds are used under what circumstances? Respondent-level data analysis, incorporating heuristics, can answer this

Pry loose the social veneers

Other strategies

Without a need and a benefit, rx is an easy target

The drug is not our customer; it’s not all about the drug

Too many “shiny, happy people” beg the question of need

Rx doesn’t confer health, wealth and wisdom, but may offer more time to seek or enjoy these things

Present rx in reality

Other strategies

In partnership, elicit and intervene in unwise or unnecessary mixing of OTC drugs, supplements and rx preps [e.g., many consumers don’t realize that Benadryl®, Sominex® and Tylenol® PM all contain diphenhydramine; many AD and OC users take SJW]

Likewise, transform non-rx options from barriers into opportunities: “I’m not dieting as my doctor recommended, so there’s no point in taking my statin, either”

While “coupling” them positively: “If you lower your fat intake while taking the statin, your cholesterol will go down further”

Leverage best and worst of other tx

Other strategies

When rx options play into becoming “normal” rather than addressing a medical need, which outcome is more likely?

Those who believe that drugs, above all, will get them “back to normal,” spend more money than time trying to get there

Low-hanging fruit for defined care: unbundling self-efficacy, self-esteem and the illusion of perfection

Though up for a challenge, most consumers want realistic goals, not martyrdom to the unachievable

Paint the red on the “normalcy” herring

Other strategies

Conflicting visions: “…our products at the center of everything we do, with the patient as the end in mind” vs. “the patient at the center with links to drugs and all other forms of treatment”

Help integrate all legitimate modalities into the consumer’s continuum of control—not a quick fix but a plan for life

Reinvent the patient-as-rx-poster-child as a success story for US health care, systems and industries (tell the care story)

“We must indeed all hang together, or most assuredly we will all hang separately."

Benjamin Franklin, July 4, 1776

Center the patient in the picture

Other strategies

In today’s and tomorrow’s industrialized cultures, the “maker” is no longer venerated

We talk internally about patients, care and diseases

But externally, US rx has lost its connection to some of the world’s finest care (considering both access and outcomes); we’ve promoted quality of care and rx products separately

Brass-tacks DTC, bland DTP run headlong into abstract labels, with little in between

Leaving consumers with “all or nothing” or “toe in the water” choices

Market outcomes, not just molecules

Other strategies

When objectives are communicated consistently across players and internalized by patients, e.g. “lower average blood pressure to 120/80,” compliance with rx and complementary health behaviors can be better linked

If we don’t help frame the outcome measures used, they will be polarized as well as less achievable

There is also a great need for simple tools to help pts share rx/OTC/ACM hx with their HCPs and ERs, and to avoid undesirable interactions/omissions

Help consumers frame and control their own most meaningful outcomes

Other strategies

DTC works best inside outViable DTC efforts will:

Monitor and integrate consumers’ heuristics, reshaping decision outcomes by understanding processes

Acknowledge the aggregate vs. member rx perception gap without a “blame game,” while promoting informed, rational decisions and thereby elevating perceived industry trustworthiness

Explicitly honor “first do no harm” and “minimal use” concepts, moving from “when diet and exercise fail…” to diet + exercise + rx “prescriptions” Consumers’ tradeoff: more to do, but less to worry has been left out and

fewer rude surprises later

Target patients, not just their “inner disease”

Establish real and perceived links with other tx modalities, and nurture holism Incent the disease managers, not only Marketing Facilitate Marketing encounters with patients Place DTC/DTP into naturalistic decision contexts Make consumer/HCP understanding of and access to reimbursement

programs a priority

That rx is sometimes “easier” than alternatives doesn’t mean it’s preferred, nor that the two are “competing” Understand the ideas and beliefs that OTC/ACM represent, before

targeting them

Addressing needs: walk the talk

Banish “medical vs. marketing” and other counterproductive dichotomies—steer the entire ship toward the consumer, payor and HCPs’ issues and decisions

Elevate the tx decision’s importance for consumers, HCPs, payors— the single best defense from commodization Without pretending that NSA choices have the import of cardiovascular

algorithms, we can present the benefit of reduction in allergy sx When the stakes are life and limb, we must not be perceived as “crying

wolf” because everyone has overloaded and tuned out Partner and keep partnering with everyone on the continuum of care…

and the consumer’s continuum of control

[email protected]

Wherever we take DTC, the patients have to be there

Laurie Gelb, MPH

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