Barriers, best practices and measuring ROI for patient compliance programs
From eyeforpharma’s Patient Persistence, Compliance & Education Conference Philadelphia, October 19-20, 2004
As part of eyeforpharma’s recent Patient Compliance & Persistence conference in Philadelphia, attendees were invited to participate in a workshop which examined common barriers to successful implementation, best practices and how to measure ROI of patient adherence programs. Three groups of conference participants offered first-hand insight into both the present and future concerns for implementing successful patient compliance programs within their own organizations and throughout the industry. The workshop was designed and co-ordinated by Rob Nauman, of Biopharma Advisors – he can be contacted on rnauman@mybpa.net In each area, not only did participants identify the most pressing issues facing patient compliance teams across the industry, but based on their extensive experience and varied backgrounds, the participant groups synthesized recommendations on potential solutions to overcome adherence barriers and to maximize compliance program ROI.
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Common implementation barriers The team that focused on common barriers to successful implementation of patient compliance programs identified two broad challenge areas: organizational adoption and patient adherence.
Organizational adoption barriers
The key organizational adoption barriers identified by the team included: • Silos (including DTC vs. professional and privacy fears) • Unproven ROI • Lack of testing due to marketers’ fear of failure • Lack of scalability in programs • 18-month lifecycle of brand directors • Lack of buy-in for “success metrics” • Acquisition not retention-oriented One area highlighted by the team was the lack of program testing. Marketers, the team said, avoid testing because they dislike spending money on “losers” or controls.
The group also said the “18-month lifecycle” of brand directors is particularly challenging. “Because these programs take at least 6 months to measure, unless you hit a brand manager at the beginning of their job cycle, they’re probably ‘out of there’ before they can see any results, keeping them from prioritising the program,” the team spokesman reported. The key barriers to patient adherence identified by the team included: • Physician denial • Lack of patient/physician feedback (episodic contact only) • Misaligned incentives • Asymptomatic diseases • Lack of patient accountability • Poor intrinsic motivation • Payer churn used as an excuse for cost shifting The group was particularly concerned with misaligned incentives, saying managed care companies really act like managed “cost” companies. “They’re not really taking on their burden or looking at the benefit of compliance programs,” the group spokesman said. As a specific example, they pointed out that pharmaceutical benefit managers, surprisingly, are often responsible for reducing the use of prescription drugs thanks to the negative effects of co-payments on patient adherence. In addition, “payer churn,” the group said, or the movement of patients in and out of managed care programs, serves as an excuse for “cost shifting” by managed care companies. Despite “churn,” however, good compliance programs would still benefit managed care companies if they took a longer-term view, the group stressed. And the group said lack of patient accountability also serves as a significant barrier, especially in the US. “There’s almost a perception that if you’re really aggressively managing – splitting your pills or missing a day – that you’re really a smart patient as opposed to admitting you’re responsible for keeping yourself well,” the group spokesman explained.
Patient adherence barriers
Detailed recommended solutions to two common barriers
The lack of agreement or “buy-in” on success metrics, the group said is something it believes is common across the industry as a reason adherence programs fail. One solution to the problem, the group concluded, is to promise brand managers specific results in dollars. “That sounds really difficult for all of us who are data-driven folks who like to use specific models for exactly why we’re going to deliver a particular dollar number, but if we can’t give a brand manager something to put on their strategic plan, we’re not going to get their attention,” the group spokesman said. The group also advocates holding vendors at risk to promise brand managers a specific gross lift. “We need to bring them in and say: ‘Hey, can we promise a 5% gross lift,’ for example, especially when we’ve heard claims from 15-40% here in presentations,” the spokesman urged. “We’re probably pretty safe with 5%, so let’s just go on the hook and do it.”
Showing the value of responders against the general market is also a valuable tool to garner brand managers’ attention for compliance programs, the team said. “Talk about the folks who respond to your adherence programs as your most valuable customers,” the group recommended. “And start to show gross segmentation and the value of those folks up front, rather than over the period of years it takes to show their lifetime value. These are the kinds of things brand marketers can relate to.” The group spokesman stressed that demonstrating positive results from early win testing and a low barrier of cost will get the attention of brand marketers. Debunking common myths about patient behaviours can also be a valuable tool to win brand team support for adherence programs, the group said. “There’s a widespread philosophy that the most adherent people will be recruited to begin with, making our programs a waste of time,” the spokesman said. “Our specific suggestion here is to quiz the brand folks on their intuitive beliefs about the patients in terms of adherence to the product and then prove a couple of those beliefs are really opposite of correct. And believe me they’ll be signing on.” For example, the group said women are often regarded as being more likely to be compliant than men, but because they are more engaged and have more information on average than men, they are more likely to question their prescription regimen and are, therefore, shown to be less compliant than men. Such an example can sway even the staunchest doubting brand marketer, the group said. Lastly, the group stresses the importance of contributing clean case studies to the most commonly used knowledge repository system used by the brand team in a given organisation to ensure programs can “survive a few brand manager lifecycles.” As a second example, the group looked closely at overcoming the “acquisition mind set.” It recommends securing frequent data feeds and analysis from vendors. “Make sure you’ve got early data coming in – monthly data feeds that are not just fed, but analyzed – so you’re bringing whatever you can to the table as frequently as you can,” the group spokesman suggested. “And you might want to aggregate some of the early data in ways that you’re comfortable with scientifically to show bigger results that will impress the brand managers early on.” The group also recommends “high-jacking” brand metrics to support program acquisition. “Basically, promise that using the Internet or another acquisition metric to get your database built for long-term adherence will also meet some of their brand needs,” the group spokesman advised. “So rather than sell the whole program all the way to the bottom and show them all the science behind it, help them see your going to hit their brand metrics and use that for a couple of brand manager lifecycles to feed your database to the point that you can demonstrate the science that’s happened over the period of a year or two.” Using things that go beyond brand metrics to demonstrate incremental Rx growth, is also a valuable tactic, the group said. “Piggy-backing on acquisition networks with lifecycle programs – so treating ourselves as an add-on to programs and not being so enamoured with explaining the entire end-to-end program up front.”
And lastly, the group advises that clearly demonstrating the cost of waiting to implement the program can quickly win over brand marketers.
Common elements to good adherence programs The second workshop breakout group examined the elements common to good adherence programs and identified best practices in the industry. Common elements of good programs identified by the group included: • Use of call and letters programs • High touch, especially with higher priced products • Understanding the research and doing work on segmentation • Designing program algorithms and conducting surveys up-front • Learning from other industries • Execute in partnership and/or in concert with healthcare providers • Focusing on increasing brand value to patient • Focusing on increasing corporate brand value • Thinking from an end user perspective • Communicating at “eye level” with patients • Having motivated healthcare providers • Executing the program • Utilizing Pas/NPs/Nurses to manage programs The group said call and letter programs, in particular, seem to work well and deliver good ROI. They stressed understanding the research as a key hallmark for common success. “If you understand the barrier to adoption and the messages that work, you will be more successful, because you’ll understand the marketplace,” the group spokesman said. And effective segmentation, the group advised, through up front surveys and assessments is a common element of success. The group also urged pharma companies to look to other industries, such as the airlines and consumer packaged goods, for examples of innovative packaging strategies. Communicating effectively, sometimes in partnership with others, such as government agencies, and at the right level, always keeping the end user in mind will increase perceived brand value for a given disease, the group stressed. The group also urged participants to careful consider whether doctors are the right people to be implementing patient compliance programs and advised that NPs, PAs and nurses may be an untapped resource to manage programs. Doctors, the group says, often lack knowledge from the program perspective and commonly overestimate their own patients’ adherence. Doctors also fail to follow-up with patients, the group says, and tend to preferentially treat symptomatic complaints.
Shortfalls in adherence programs
Things • • • • • • • identified by the group that are not working in adherence programs include: One size fits all approaches Expecting others to do the work for you Nagging/direct mail reminders One way communication Big ideas without execution Complex technology Candidate identification techniques
The group stressed that adherence programs that rely heavily on physician participation are very likely to flop, because doctors don’t devote the time or effort that most such programs require. The group also questioned the continued value of “nag” refill reminders. “They don’t seem to be working as well as they used to and may have hit their peak in the market,” the group spokesman said. And he stressed other forms of one-way communication also are not effective. “If we’re really going to be successful, actually getting a two-way dialog is going to be really critical for common success in the future,” he said. The group contends “execution may be the real competitive advantage,” but they cautioned on using complex technology, saying doing so often leaves you starting out behind if the technology is difficult for people to grasp. Appropriately identifying patients to target is also a key challenge and the group cautioned against the negative impacts of misidentifying and targeting individual patients.
Who should lead compliance programs?
The group recommends a cross functional team, including members from managed care, the professional side of the brand, the consumer side of the brand, and trade and clinical affairs because of some of the Phase III and Phase IV work. The team should also include health outcomes players and patient groups, as well as key opinion leaders and healthcare practitioners, the group advises.
Return on Investment The third and final group from the workshop breakout sessions focused on measuring the ROI of patient adherence programs. Consistency and flexibility were key challenges identified by this group. “Basically, when you have ROI measures coming in from multiple agencies or brands, each doing things differently, how can you really know comparatively how a brand program or even within one channel versus another channel is performing?” the group’s spokesman asked.
To meet this challenge the group recommends a standard framework for ROI. “That doesn’t mean a standard interpretation or standard values for ROI measurement,” the group says. But it does require a standard framework or structure that allows you to manage margins in a similar way, for instance, or similar calculations to determine value. The group also stressed the importance of getting finance to “buy into” the framework. “Often what happens is that ROI is something between a brand and their agency and the finance group within the company isn’t necessarily involved,” the group said. “And this is a mistake at times, because often when it becomes important in terms of how programs perform, and finance becomes involved, they’re likely to feel things are not being done in a way that is valid for the company. So the idea is to solve this issue of consistency for roll-up and comparison in a standard framework that is validated by finance. A rigorous testing process for how each agency and each program measures ROI is also important, the group advises. “So, the idea here is to be able to say OK we’re going to separate this by segment, we’re going to separate this by channel, we’re going to validate this by looking at how you’re plugging in these numbers into this framework and ensure that all of the assumptions are applied consistently,” the spokesman said. Tallying and communicating brand successes so they can be shared across the organization is also important the group concluded. “A strong success based on ROI is something that ought to be replicated across brands and many aren’t even aware of that happening,” the group said. The best approach, the group contends, is to systematize access to the information using knowledge management tools that require brands to enter results and assumptions about campaigns, as well as business cases to validate an approach in a real context. Despite having a standardized framework, the group stresses the importance of maintaining flexibility to interpret results and establish benchmarks considering often vast differences across brands, such as brands for chronic conditions versus episodic or seasonal brands. The group also identified cross industry expertise as a key component to the success of adherence programs. Especially in light of the constantly changing brand management side of the equation, the group urges teams to include permanent quantitative analysis members, who can provided the continuity required for quality measurement of ROI across the board. In conclusion, the group encouraged a systematized process that makes a standard framework and KM platform available, accessible and usable in an easy way to marketers.
This report was written from Rob Nauman’s notes by Lisa Roner, Editor, eyeforpharma. Contact lisaroner@eyeforpharma.com
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For more information on eyeforpharma’s Patient Persistence, Compliance & Adherence services, contact: Europe Izzy Wakeling iwakeling@eyeforpharma.com +44 (0) 207 375 7522 USA Paul Simms psimms@eyeforpharma.com +44 (0) 207 375 7194 Sign up for our free email newsletter every two weeks - on pharma sales & marketing strategies: http://www.eyeforpharma.com/subscription For anything else to do with eyeforpharma, contact: Paul Simms psimms@eyeforpharma.com +44 (0) 207 375 7194