Getting Serious About Adherence

Great post today from John Mack’s Pharma Marketing Blog today about adherence.

First, Mach cites an amazing 2003 World Health Organization report on the problem that estimates that worldwide, something like 30% to 50% of medications prescribed  aren’t taken as directed. This reminds us of Lord Leverhume’s famous observation about advertising, that 50% of his advertising was being wasted, but he didn’t know which 50%.

The WHO report, although five years old, is a comprehensive review of the adherence problem all around the world. You can download it here.

Mack then goes on to introduce us to what seems to be a less-than-serious adherence tool — a collar that, when worn, senses when pills have been swallowed. This requires, however, that the pills be implanted with tiny magnets that the sensors can pick up. Uh, no thanks. For one thing, it closely resembles the kind of collar used to train hunting dogs using electric shocks. See for yourself:


Magnetic sensor collar for improving pharmaceutical adherence.


Electronic shock collar for training hunting dogs.

More seriously, though, the big issue with adherence is fairly straightforward — it isn’t easy. To quote his post: It’s not easy to get a good return on investment from a
compliance/adherence marketing/patient education campaign. That’s why
the vast majority of pharmaceutical marketers continue to focus on the
"low-hanging fruit," i.e., new prescriptions (new patients).

This we knew also. Adherence is not simple, and not easy, but when executed correctly, it’s extraordinarily effective, and the ROI is phenomenal. And also, hard as it may be, it’s got to be a lot easier than convincing patients to strap on a collar with batteries and flashing lights. I mean, at least until that thing comes in platinum.  

“I could trust them to set up a good IVR…”

In this post, I’m going to look inward at the RM agency side and not at  marketing or industry issues. Why? Well, my interest in this was launched by a conversation with a pal of mine who is very successful pharma marketing consultant — one of the best there is. He recently told me that  he was tired of having to watch over other agencies as they implemented one of his segment-ROI driven plan. Describing one of the oldest, largest and venerated DM/RM agencies, he said, "Well, I’d trust them to set up a good IVR call center, but they seem stale otherwise."

Agencies, like any company, are unequal in their distribution of skilled personnel. But I know this agency, have worked there, and knew exactly what he meant. Their sheer inertia and size made them just plain slow on all fronts. It annoyed me that they had a very large  RM account and yet were "stale." It just seemed unfair to the client.

Then it struck me — who better than an agency to help a client avoid this? To craft an "Are You Right for Us" quiz for a client to use. Who else knows better what questions clients should be asking their pharma agencies? 

There’s an old saying that clients get the advertising they deserve, which is another way of observing that perhaps The Peter Principle applies to client-agency relationships.  In case you’re not familiar with it, The Peter Principle, coined by Lawrence Peter in 1968, holds that in every bureacracy, people keep getting promoted until they reach a job they cannot handle — i.e., people rise to their level of incompetence.  Perhaps clients and agencies both tend to grow until they respectively prefer, and provide, mediocre work.

But try these out for some starter questions:

  • What is your position as an agency?
  • Who will work on my business and for how long?
  • How do you keep the work fresh?
  • What is the role of research?
  • What is your POV on RM?
  • What do you know about our patients?
  • What do you know about our overall business?
  • What is your POV on ROI? (And be open to discussing LTV, too.)
  • How will you challenge us? (Clients, be fair!)
  • Why are you the best choice for us? (And please no cliches.)

As an initial pass at a list, this hits what an AGENCY wants you to ask — but also fears you will. Agencies do not like clients getting too close. Relationships, yes; go under the hood, no.

For an agency, there’s a Part II to this — How Will You Train The Client in RM? No matter how much clients think they know, you hire the agency people because they are the experts at RM.  You want the best — both to deliver the work and to act as teachers. You want the best training you and you  staff can get on the tenets and trends of good RM. Your agency should be able to tell you how they can make this happen.

You Have To Give Them A Reason

Today in the DTC Marketing Blog, Richard Meyer made one of those observations that is so simple and so obvious that it just has to be true. And insightful. Writing in a post about the concept of including an 800 number for the FDA in drug as, Meyer made this observation:

"When starting any CRM program one of the key questions you have to ask is "What’s in it for my customers to start a relationship with my company?"

That, in a sentence, is what really defines RM.

Istock_000004747235xsmall When someone goes to the mailbox, or goes online, and instead of simply pushing an ad at them, you are asking them to respond somehow, it is simple human nature for them to ask themselves "Why should I do this?"

You are asking for their time, their attention, perhaps for some information.

It isn’t necessarily possible for you to deliver value right then and there, on the spot, although sometimes you can. As a reason for them to respond, you may provide them with information, or insight, or discounts.

More often, however, what you’re providing is the promise of value, what lawyers call an executory contract. "If you give me some information, I will provide you with value." And in any kind of RM, but particularly in pharma, you absolutely must deliver.

Ultimately, your customers are the ones who are calling the shots in this kind of project, because they are the ones defining value. This is a critical distinction. Value here really is in the eye of the beholder, and the more personalized and distinct what you deliver is, the more valuable it is to them.

Interestingly, one of the least valuable things you can provide for customers often is money — in the form of a discount, a rebate, a free sample or whatever. This is by no means a universal or hard-and-fast rule, but value is a subjective, interpersonal concept. What is truly valued may be something emotional, or inexpensive, or surprisingly simple. And further, the customers who do tend to respond to money — who can be bought, basically —  are often fickle, or not inclined to be loyal.

The question, always, boils down to "Why should I?" The key to the whole enterprise lies in how you answer that question. Here’s a hint: "Because I want you to" is not the right answer.

RM In the News — Again

Last week it was nurses. This week it’s pharmacists. Either way, RM is emerging, bit by bit, as the weapon of choice for holding down healthcare costs. Or at least, so says the Wall Street Journal.

In a story yesterday, the Journal reported on a trial program written up in the Archives of Internal Medicine. In a dozen tracked, randomized trials, regular consultations with pharmacists significantly reduced hospitalization rates for patients with heart failure.

Although the role of the pharmacists varies, generally they help patients stay on their meds, and monitor their basic condition. A similar trial is under way for diabetic patients in 10 cities across the country, in which pharmacists coach diabetics. Both diabetes and heart failure are condition in which regular, consistent use of medication plays a key role. These patients have seen a significant improvement in their blood sugar levels.

The grandmother of all these programs is, of course, the famous Asheville Project. In this pioneering program, the city of Asheville provided city employees with health education, and monitoring and assistance from pharmacists. The program was a classic win-win-win. The patients had greater adherence, better outcomes, lower costs and increased satisfaction with their pharmacists. The city saw lower costs and happier employees. And the pharmacists got to expand their role in the healthcare equation beyond simply dispensing pills. Essentially, by creating an ongoing relationship between the pharmacist and the patient (a relationship, we might add, which is vastly more expensive, complex and difficult than a marketing or patient education campaign) patients were much more likely to stick with their therapies, manage their conditions well, and maximize the benefits they saw.

The bottom line, as always, is that healthcare is at least one part human behavior and participation for each part science. This is especially true for chronic conditions. All programs are not created equal, of course, and your mileage may vary. However, this may portend an expanded new role (or perhaps a return to an old role) for your friendly neighborhood pharmacist. Stay tuned.

RM In the News

A really interesting story in today’s New York Times about an attempt to use what seems to be a flavor of RM to bring Medicare costs down.

The story concerns a program called the Medicare Health Support program. Eight companies participated in the test, which affected roughly 160,000 patients. According to the Times, the program simply involved having teams of nurses maintain telephone contact with patients to insure that they are taking the right medications, and seeing their doctors.

It’s unclear at this juncture whether or not the program actually creates cost savings, but prelimiary data doesn’t look promising. The story says "Experts say that Medicare and the companies alike were too optimistic about how easy it would be to prevent costly complications and hospital visits by patients who are very sick." The participating companies claim that Medicare has hindered their ability to delivery results by enrolling patients who were far sicker than initially planned, and by failing to provide timely information about lab results , the use of prescription drugs, and so on.

A couple of thoughts. First, this isn’t really RM, although it mimics some of RM’s characteristics. It is, rather, a kind of medical outreach program, targeted at extremely sick patients — people suffering from serious cases of diabetes and congestive heart failure, for example.

Second, compared to the costs of an RM program, having nurses, as in this trial program, personally contact individual patients, is enormously expensive. The RM toolkit typically contains much less expensive, yet effective, contact methodologies — online, direct mail and so on. Direct one-to-one contact strategies are an entirely different matter.

Interestingly, though, the Times story did vividly demonstrate the enormous need for patient information. One nurse, Jill Coker, who made 25 to 30 calls per day, told the times that most of her time was spent on "rudimentary issues, like explaining to patients what prescription drugs they are on and helping them devise ways to make sure they remember to take their medicine." She is quoted as telling the reporter that "There have been numerous diabetics who didn’t even know what an endocrinologist was."

That should make anyone stop and think for a second. These are very sick patients, whose lives depend on being on top of the management of their conditions. Congestive heart failure is a very serious ailment. Yet, despite this, as Ms. Coker and her fellow nurses demonstrate, there is a widespread, pervasive lack of knowledge about how to best manage this illness.

And if there’s such a dearth of information for heart failure, one can only imagine the situation for patients with less severe chronic conditions, or those which are asymptomatic — hypertension for example.

There’s no real question that improved adherence and better outcomes are the result of true communication with patients, and the delivery of information and service. What this pilot program may demonstrate, though, is that a marketing approach rather than a healthcare approach may be the way to go about it.