Archive | December, 2008
Dec 18th 2008 

Pharma’s Cutting Reps, But Can Effectiveness Increase?

Each day it seems like another pharma company is cutting more of its workforce including sales reps. BMS announced the latest just yesterday and Sanofi-Aventis the week before saying they could cut up to 10% of its field sales force. These are just a few of the many cuts announced this year. Overall, it’s apparently been a tough year for pharma employees, especially sales reps.

Some questions to consider:

Question one. Are there too many reps out there? Are they all needed? There are about 900,000 doctors in the US and about 100,000 pharma sales reps. 1 rep per 9 doctors. That’s always seemed like a lot to me.

Question two. Does quantity equal quality? I don’ t know the answer and I’m not going to cite a bunch of fancy research. I can tell you that many companies have quotas for the number of face to face calls required each day for a rep and it can be as many as 10 or 12. Considering that only 25% of visits actually result in a face to face call, that’s a lot of visits to get 10 in a day (40 for those doing the math at home). That doesn’t seem mathematically possible to me considering how long a day is. Those that do get a face to face often get about 90 seconds according to the Hay Group.

Question three. Are reps worth the cost? Each rep costs a pharma company about $200k a year. That includes salary, bonuses, benefits, car, etc. That’s a pretty big fixed cost. Consider a drug that costs $50 per month.  To generate $200k in incremental revenue (not even profit, revenue), each rep would need to get about 77 additional prescriptions a week or about 15 a day (5 days a week, no vacation either). Remember that a lot of prescriptions would be written whether there was a rep or not. Are your reps getting 15 additional prescriptions a day? I doubt it.

Apparently, some companies are starting to figure this out and that’s where the cuts come in. As I said, I’ve always thought that there were too many reps. You probably noticed too just by looking around your doctor’s office some days.

So what does all this have to do with digital? Well, these pharma companies who are cutting back on one of their most beloved (to them anyway) and effective (to some degree) promotional tools still have the same lofty sales and profit goals. That means the remaining reps likely need to deliver the same revenue as they always have. This means increasing effectiveness. With less people, you need to increase each rep’s reach, ensuring that they’re around even when they’re not physically there.

One way to do this is through e-detailing. While that means a lot of things to a lot of people, here’s how I define it. It’s an online detail (product sales pitch if you will) that allows the doctor to view the detail at his or her own pace whenever they want online. I’m not talking about a detail with a live video feed of an actual sales rep. Different story for another day. 

Let’s be honest. The vast majority of pharma e-details are terrible.  Most of them are simply electronic versions of their paper visual aids. The doctor is expected to click through each page with no interaction, no accounting for the doctor’s needs, and no customization. Who wants to sit through that? Basically, it’s like me asking you what you hate about this blog. You say it’s the seemingly never ending length of some posts. And instead of addressing this, I tell you that it has an amusing header picture. How would that leave you? Annoyed. At best. You’ve got to address what’s relevant. It’s what these companies expect their reps to do live and in person, but they don’t expect their e-details to work that hard.

Fortunately, there is a simple answer to this. For example, my company, Bridge Worldwide, has developed an e-detail platform that has the following features:

  • Customized tracks based on physician choice (you tell me what you want to know)
  • Objection-based tracks (addresses the physician’s biggest issues with the drug)
  • Current product usage behavior (what does the doctor use now for select patients)
  • Interactive quizzes
  • Peer to peer knowledge challenges (did your doctor friends know the right answer?)
  • Post detail effectiveness tracking (did the detail change your opinion, why or why not?)
  • Message tracking (which messages have the biggest impact)
  • Field sales alerts (so they know what messages are working the best)

If your e-details don’t do all of this (at a bare minimum), they’re likely not having an impact. It’s also likely that you don’t know whether they’re having an impact, because you’re not tracking the effectivenes if you’re like most companies. 

Why do e-details need to be like this? Simple. Doctors are human beings whose online behavior is very similar to everyone else’s. So, your competition for the doctor’s time online isn’t other e-details, it’s everything online from YouTube to email to news to Hulu and so on. Doctors, like the rest of us, have an expectation of how things should work online. This applies to everything including e-details. “In the land of the blind, the one eyed man is king theory” may work in some cases, but not online. Just because you have the best of the e-details, you still might have one of the worst sites when taking the Internet as whole as your competition. So, don’t just do one better than your pharma competition. You’ve got to do better than everyone else online to get the physician’s attention. 

You’ve got seconds to do it. Think: would your current e-detail make you stop?

Dec 16th 2008 

Medical Jargon Makes You Sicker (Sort Of)

During my daily perusal of all that is healthcare online (and that’s a lot to keep track of), I came across an interesting study that was pointed out by KevinMD.com. What it found wasn’t terribly surprising, but it was a great premise to test. The gist of the study was to figure out if your doctor gives a diagnosis using medical jargon,  is it interpreted as being more serious and less prevalent (i.e., more rare)? A few of the terms they looked at were “newly medicalized terms,” like erectile dysfunction versus impotence compared standard medical terminology like myocardial infarction versus heart attack. What the study found was that only the recently “medicalized terms” caused people to think they had something worse than what it actually was. For whatever reason, when using standard medical terminology (like myocardial infarction) people were not confused.

The study’s bottom line is summed up here: “A similar pattern was not seen in the established medical conditions, even when controlled for severity. This study demonstrates that the use of medical language in communication can induce bias in perception; a simple switch in terminology results in a disease being perceived as more serious, more likely to be a disease, and more likely to be a rare condition. These findings regarding the conceptualization of disease have implications for many areas, including medical communication with the public, advertising, and public policy.”

Okay, here’s my take. When doctors used the medical terminology patients actually understood what disease they had and how severe it was. Credit that to all the medical shows on TV I guess. On the other hand, when people were told they had one of these “new” conditions, things looked pretty grim in their eyes. Two of my favorites: Chronic Fatigue Syndrome becomes “Myalgic Encephalomyelitis” and Skin Tags (you know ‘em if you’ve got ‘em) becomes “Acrochrodon.”  Pretty sure no one wants to hear anything from their doctor that has “enceph-” in it. The rest:

"Medical" Terminology

For the record, I’m going to make no pronouncements against the pharma companies that likely created many of the “Recently Medicalized” disorders. Where the problem lies is instead how this information is communicated.  Even with these convoluted names, there’s no reason for anyone to go on thinking they have a much more serious condition than they actually do. It’s not a great way to go through life. This lines up conveniently with the recent Microsoft study on “Cyberchondria” where people self-diagnosed themselves with the worst possible diseases. So, the blame doesn’t rest entirely on the patients. Physicians need to improve their communication skills.

However, the reality of our medical system is that most physicians simply don’t have the opportunity to spend even 15 minutes with a patient talking about their disease. They are forced to hit the high points and do their best in the time they’ve got. From there, patients are on their own. But does it need to be this way? Glad you asked. The answer is “no.”

Consider how digital technologies might help here. Instead of just a few confusing minutes with the patient, the physician comes into the exam room with a customized pamphlet that his nurse just printed for him. On the pamphlet is a customized URL that links to a page designed entirely for this specific patient. Not this type of patient, not this disease. This exact patient. With the powerful content management systems (CMS) available today, this doesn’t have to be an amazing feat. Instead, the nurse answers a handful of questions, selects appropriate content and hits “print.” At the same time, a customized page is created online for the patient to review later.

Simple. No one walks away thinking they’ve got something worse than they do or confused about what to do next, they’ve got a customized answer just for them. If you’re going to provide information for patients on a website, you’ve got to include some simple segmentation that ensures that people only see information relevant to their condition. Consider an advanced lung cancer patient who arrives at your site to find some “background” information on lung cancer including risk factors, prevalence, and how to prevent it. Do you think they care about this? Probably not at this point. How does seeing this information on your site make them feel about your brand? At the same time, a stage 1 lunch cancer patient doesn’t need to see that there’s a 2% 5-year survival rate for lung cancer. That’s for advanced, but is often quoted as THE number. Instead, ensure they see the early stage number, which is far more positive (50%).

With all the content available out there, why not make it more accessible and more relevant to each patient? If we’re talking about customized medicine lead by genetic testing and specialized drug combinations, why can’t we simply have customized websites? Seems like a lot simpler start.

Dec 11th 2008 

Nag…I mean…Reminder Letters

Yesterday’s post about compliance was pretty popular and generated a number of comments, so I thought I’d continue a bit with that theme. I received a piece of mail yesterday that sparked my memory about another big issue around compliance and one of the more common techniques that is used to try to improve it. I call them “Nag Letters,” but they’re technically called “Reminder Letters” I suppose.

You’ve likely gotten one of these before. It’s a letter from your pharmacy (maybe, keep reading) that reminds you that you haven’t filled your prescription in a while and it’s past due. It then goes onto remind you of all the reasons you should be taking the medication and potentially what might happen if you don’t. It’s a rather unobtrusive reminder, a courtesy I guess. No one really gets hurt or probably too bothered. It is your pharmacy after all, so they’re just trying to help. You probably should know that most of these are paid for by the pharma company who markets the drug you’re being reminded about. I personally, don’t think that’s a big deal. They don’t get access to your information, they simply pay the pharmacy to take care of this for them.

The intention is good. Your doctor wants you taking this medication presumably to make you healthier and they’re helping make sure that you do. Clearly, the pharma company has a stake in you refilling your prescription, but so what? This is probably the most innocuous form of direct to consumer (DTC) marketing that a pharma company can do. You’re simply reminding current patients who should be continuing a drug to keep taking it. Everyone benefits, right?

Here’s where it gets dicey. Who’s responsible for sending out these reminders? Who has a vested interest here? The interest may be your health or the company’s finances, but have you stopped to think who might send you a letter like this? This someone has to have information on what drugs you’re taking. So who’s got this information? 

As a former brand manager, one year we were pitched a number of these programs by different companies and even other divisions within our company. At the end of all this, we discovered that if we did all the programs, a single patient could potentially receive 6 (yes, 6) different reminder letters from different entities. Who? Here’s the list along with the incentive for each company (besides the moral fact that each group wants patients to be healthy of course). This is sure to offend someone, but I’m trying to make is simple here:

  • The pharma company that makes the drug: more refills, more revenue
  • The pharmacy that fills your prescription: more refills, more revenue
  • Your insurance company: compliant patients end up costing less in medical benefits later
  • Your doctor: if your treatment works, you stay their patient
  • The pharmacy benefit manager (PBM): more refills, more revenue
  • The physician network (a large national group [such as US Oncology] practice with many independent offices): better compliance, better outcomes to report

Six letters all saying the same thing arriving at roughly the same time. How do you think that would make you feel as a patient? Annoyed for sure. Probably concerned about the security of your health information. And likely more inclined to stop your treatment.

So, why do these programs exist? Simple math. These programs “work.” Reminder letters “work.” I use “work” in quotes intentionally. These programs result in more refills and more revenue for interested parties, but do they really impact compliance? They don’t. In effect, these programs encourage a handful of people to refill their prescriptions a few more times each. Because these programs are relatively inexpensive to run, there’s usually a very positive ROI. However, these programs don’t change people’s perceptions of the drug, nor do they change the person’s deep seeded understanding of why this drug is critical to their health. A standard form letter cannot do that.

There’s not really a digital lesson here. I’m not going to tell you that 6 emails is better than 6 letters (though recipients might think email was better because they can block the next one). My point is simply this: just because you can do something doesn’t mean you should. All of those groups who could send those reminders should all be working together to create something that is likely to truly impact compliance. Instead of making a short-term spend for quick revenue, why not take that same money and invest it in understanding the real reasons why people stop their treatment? From there, you can create programs that will be more effective by huge orders of magnitude.

So before starting your next initiative ask yourself: “Am I doing this just because I can?”

Dec 9th 2008 

“Glorified Alarm Clocks”

One topic that you’ll probably see quite a bit about in the future on this blog is drug compliance. Perhaps you call it adherence, but whatever you call it, the situation is bleak. I’m referring, of course, to patients that don’t take their medications as prescribed by their doctors. I’ve seen a number of figures, but one of the more popular papers written on this topic by Lars Osterberg pegged just some of the cost of non-compliance at over $100 billion a year. There’s also no question that for many diseases, a lack of compliance leads to worsening of disease and also an increase in the risk of death. One study looking at non-adherence to medication after a heart attack found an almost 4-fold increase in death one year after the event. That’s bad.

Consider that last stat. Presumably, the doctor has told the person the importance of the medication and their risk if they don’t take it. I’ll also assume that people generally want to live. So then how come so many people stop taking their medication? Truth is, no one knows because the answers are so individualized. What impacts one person may mean nothing to the next. However, almost every program ever created to address non-compliance has focused on a one-size fits all approach. The way I sum it all up is like this: “We try to impact everyone, yet only really impact a few, and even fewer to a great extent, and we do it inconsistently.”

I’m saying “we” because in my past job, I led some of the compliance initiatives for Arimidex, a breast cancer treatment, at AstraZeneca. Yes, there are problems in adherence in breast cancer where almost 1 in 5 women stop their treatment after a year (instead of the typical 5 years they should) and increase their risk of recurrence by more than 20%. No one has figured out how to fix compliance and pharma companies and physicians have tried for years. Anyone who tells you they’ve got it figured out probably is exagerating a bit. 

So, when the most recent issue of Pharmaceutical Executive arrived, I was interested in their story about “Tech Toys” designed to improve compliance. Some of the ideas were interesting and some a long way from ever being accepted by patients. As I read through the gadgets one at a time, I realized that they were all pretty much the same thing. They were either elaborate reminder systems or snitches. They blink, buzz, text, call, or email when you miss a few doses or they call and tell someone you missed your dose. What bothered me the most was that each company featured thought their idea was light years ahead of everything else and was going to be the solution to the problem we’ve all been seeking.

One in particular stood out to me and was really the impetus for this posting (and inspired the title). A company called Vitality  has created a device that fits on top of your pill bottle and has a sensor that tracks if you’ve taken your medication (actually it only tracks if you opened the bottle, which is not necessarily the same thing) and a little LED light that blinks when you don’t. Check it out below.

The part that bothered me was this. The company’s CEO, David Rose, put together a quote for the article, as follows: “People just aren’t taking their medication as prescribed—especially for asymptomatic and chronic diseases; the research shows adherence rates as low as 50 percent. The research that we have seen is that the problem isn’t just a reminder problem. There are a lot of devices on the market that are essentially glorified alarm clocks.” I added the bold to add some emphasis. The device then is described in the article: “It’s basically a smart medication vial cap that fits the standard bottle. Inside is an LED and a sound chip, as well as a two-way wireless radio that connects to a set of Web-based services that include reminder calls, weekly e-mails, monthly reports to a doctor, and refill service at the pharmacy [emphasis mine again].”

So, if Mr. Rose says it isn’t a “reminder problem” and that most devices are “glorified alarm clocks,” how is his device which includes services such as “reminder calls” and “weekly emails” not a reminder device that’s a “glorified alarm clock?” The answer is that it is. This device is a glorified alarm clock. Just because it doesn’t ring and sends an email instead doesn’t change this fact. Using digital, such as email, doesn’t inherently make your product better or change it’s basic function.

If reminders worked, then simple beeping alarms would have solved the compliance problem long ago. The way I look at this is for a serious disease like breast cancer, isn’t opening your eyes each morning enough of a reminder that you have a disease that could kill you at any point? I’d think that might remind you about your medication. If reminders worked, wouldn’t the fact that you could die be reminder enough?

The reality is that compliance isn’t a reminder issue. It’s a complex phychological issue. People don’t take their medications for a number of reasons many of which include the patient’s decision that the drug isn’t helping them or isn’t necessary. Very few patients are informed enough to truly make this decision (they’re called doctors though) and yet it happens every day. People aren’t convince themselves that the risks outweigh the benefits or that they are feeling fine, so they must be “cured.” Point is, it’s something different for everyone. Very few people actually stop because they simply can’t remember.

So, we have to change this mantra: ”We try to impact everyone, yet only really impact a few, and even fewer to a great extent, and we do it inconsistently.” Instead, it needs to be this: “We find only those who need help, so the impact is magnified, because we learn what they need to help them consistently over time.” Digital technologies allow us to quickly segment individuals and find who needs the most help (and who wants it). This allows you to dedicate more resources to these people instead of spending a little on everyone and having no impact on anyone. There is no reason that each person in a compliance program doesn’t essentially get their own, completely customized program. If we really want to make an impact on compliance, this is what needs to happen.

I’ll be talking a lot more on this subject in the future, but for now I figured I’d at least set up the problem. Curious if you’ve had any success with compliance programs or any failures you’d like to share. What’s worked and what hasn’t? And you even tracking these programs to know that answer?

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