Where Does DTC Go From Here?
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Where Does DTC Go From Here?

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Updated presentation from Defined Care 2004 summit on the role of rx drugs in society with implications for marketing, managed care and disease management.

Updated presentation from Defined Care 2004 summit on the role of rx drugs in society with implications for marketing, managed care and disease management.

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  • We are Puritans still “ Doc in a box” – demeaning term, never caught on because we want to feel individual care given – but now showing up in Krogers with NPs – diminished scope “ Fix in a bottle” won’t catch on, either…we take it, but we don’t feel good about it, and there’s a lot of impetus against it, e.g. DARE
  • Lots of barriers to taking drugs, taking drugs right We put on pedestal but also pitch as right here, right now – instant access Does it look like we are touting the access or the drug?
  • You can’t feel about your drugs the way you feel re the industry – you wouldn’t take them Any more than you can feel about your doc how you feel about your insurance company, or the system in general Still basic tension between wanting to believe health care/ rx is healthy, good, extends lives and… If you use these resources, you are not addressing the real problem—you’re avoiding it, back to the Puritans – sense of need for self-denial – am I worth these resources?
  • Some auto insurance is cutesy – some is somber.
  • Reimportation – we have the right to pay less and it’s absolute But scare tactics around counterfeiting, potency,
  • No drug is 100% effective and safe for all So why do we market as if audience is homogeneous?
  • Health vs. disease position Blurring line for when to seek care and when to seek drugs (OTC, supplement)
  • A single word can be important – what does it mean? Do more 1 x 1’s because of social bias in groups
  • There is always responsibility in taking a drug – you are putting something into your body that can have severe consequences – but what are the benefits? What are the risks? The fast voiceover at the end sounds like we’re buying a car
  • We know how much involvement with picking a pipe, house or car is optimal – the parts to “leave to the experts” are clear Not so with health care – many voices say trust doctors, others say “only trust yourself” So how active should we be? The stakes are high, so erring on one side or the other, against one’s own impulses, is common.
  • I want to believe that rx is tailored to me; DTC says the opposite.
  • We need to feel that we have control more than we need it.
  • Does CDH support either of these messages in regards to rx? Does CDH support the “health as money” doctrine in regards to rx? When it does, it’s a mistake. When we think that, we lose all faith in the “art” and believe in the cookbook. And safeguarding health is less precious to us as indviduals.
  • Public Citizen doesn’t want emotional appeals to put people’s health at risk Neither do we But this is disconnected
  • Realism trumps empty promises – we don’t keep buying cars that don’t run well Think of increasing sophistication of consumer – we’ve come a long way, baby – no more bacon breakfasts with a cigarette, marathon running for fun, etc.
  • We need to answer the spoken and unspoken questions, not wait to be asked
  • Some very nice patient education, and the best links you, the rx, and the outcome – all bound together That’s we need more of – not “you take drug and become something else” -- disassociation
  • Confusion breeds both fear and anger Anger breeds both fear and contempt Opting out…becoming a junkie…similar motivations
  • So if Humana thinks my disease is mine, not the drug’s to change, and I don’t… We both blame the drug co. for not providing better evidence
  • Now I don’t know if I did the right thing, and whether it would be worse to d/c the drug I am susceptible to the environment, because I have not yet internalized its beneifts
  • Fear of health care system can lead us back to the safe harbor: drugs Drugs don’t say, “how is your diet? Have you been walking? Are your parents living?” They don’t question But they require faith and hope to take
  • The idea that supplements are more natural is dangerous Treat all substances with respect, including food It’s your body, not ours
  • Again, rx is just part of your world – not a substitute for it
  • Most DTC doesn’t mention OTC and supplements – bashes other rx, maybe But what is least likely to help the pt who really needs rx?
  • Encourage realism You are not going to feel good every day, all day Nor will rx or any substance change that When we let supplements take the lead, people feel worse than they did, because the benchmark is so far out there…shiny, happy people everywhere But we don’t want to feel like we are really missing the boat or worse off than others. Run with that!
  • Rx not trial and error – think about it and ask your HCP to do the same GIGO
  • The pt wants to help herself Help her Encourage her Pt education is getting there, but then DTC deflects
  • Article in Star Ledger – we are hiding discount programs
  • All disease is not created equal, just like anything else Do you look at your leaky faucet or your leaky car first? Help formulate decision rules – distinguish between allergy sx that are and are not bothersome

Where Does DTC Go From Here? Where Does DTC Go From Here? Presentation Transcript

  • “ 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
  • “ Feeling good” or “feeling better—” when do needs differ from wants? Luxury Survival need Means to end Self-contained Massage therapy? Allergy meds? Rx/OTC/ACM is unique Higher education Employment Entertainment Leisure travel Home electronics Fashion clothing Upscale housing Housing Food Warm clothing Acute rx/tx
  • 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 right time, 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 Poverty Denial Fear
    • 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…
    Thinking about rx means… Generalizations are tempting
    • 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
    Consider the contexts When/why does the right thing seem right?
  • 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
    Method in the message: We can make the right thing seem more right
  • 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?
    (Still) Taking rx is… a leap of faith into a decision
    • 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
    Taking rx is… sometimes, having to think you’re sorry
    • 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’
    Taking rx is… more than a single decision
    • 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
    Points to make Interfering with “nature” often improves/extends life
    • 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
    Points to make Even with rx on board, you’re still the driver
    • 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
    Points to make With great power comes some responsibility
    • 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
    Other strategies Pry loose the social veneers
    • 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
    Other strategies Present rx in reality
    • 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”
    Other strategies Leverage best and worst of other tx
    • 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
    Other strategies Paint the red on the “normalcy” herring
    • 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.&quot;
        • Benjamin Franklin, July 4, 1776
    Other strategies Center the patient in the picture
    • 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
    Other strategies Market outcomes, not just molecules
    • 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
    Other strategies Help consumers frame and control their own most meaningful outcomes
  • DTC works best inside out
    • Viable 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_address] Wherever we take DTC, the patients have to be there Laurie Gelb, MPH