1. Patient Information in an Era of Change Louis A. Morris, Ph.D. Senior Vice President PRR, Inc.

2. Communications Change Source –from HCP to Manufacturer Channel –from personal and print to mass customization –internet Message –from health education to marketing Audience –from dumb terminal to active decision maker

3. Thesis Redefinition of communications structure creates new opportunities We need new thinking –marketing approach to patient education Implications for Pharmacy –public health advocates –implementers of cultural change –who pays?

4. Patient Info Sources: Traditional Manufacturer Independent Face to Face Mass Media Through HCPs Through HCPs Help Seeking/ Reminder Ads Public Service Ads

5. Patient Info Sources: Modern Manufacturer Independent Face to Face Mass Mass Media Customization 1-800 #s HCPs DTCA PSA/En- dorsemts Database Marketing Infotisements Registries HCP/Com- mercial HCPs - Start Kits Public Relations

6. Blending –Starter Kits - info packages –Disease/Drug Newsletters –Registries –Clinical Experience Trials –Direct mail –Ads in direct mail pubs –Ads in patient information at Pharmacy

7. Blending on the Internet Is it independent content or an ad? What is the Source? Search Engine Results? Paid Linkages? Future Increase in Internet Use –Multimedia Content – Faster Access, Smart Slaves, Always On less active search, more passive use

8. Blending - Resch Questions How important is source credibility in patient information? How important is face-to-face? –Hi tech/Hi touch How does this affect pharmacy? –Pharmacist rated highest in credibility –Pharmacists viewed as most accessible –Ability to take advantage?

9. Why DTCA? HCPs MCOs Pat’s Gatekeeper ++ ++ Influencer +++ + ++ Therapy Selector ++++ + Buyer+ + User + ++

10. Message Evolution User: –“Finish all your medicine, even if you feel better” Gatekeeper: –“The doctor has treatment programs that can help” Influencer: –“Easy to swallow”

11. New Messages User: Medication Compliance - Will there be a rebirth? –Barrier Assessment Tools –AARDEX (MEMS Monitor) as a feedback tool Influencer: Quality of Life –FDA barriers –Implicit, “benefit-related” messages –symbolism

12. Message / Audience Interaction: Patient Information Processing Willingness and Ability to Learn –Motives - Message Involvement/Goals –Ability - Literacy/Self-efficacy –Opportunity - Task Constraints Perceived and Actual Cognitive Load –Simplification –Signals

13. Audience Tailoring - Stages Smoking Cessation: Precontemplation, Contemplation, Preparation, Action, Maintenance Abstinence at 18 mo: –Single Brochure11.0 –Individualized to Stage18.5 –Interactive feedback 25.2 –Personalized (calls)18.0 Velicer et al., 1993

14. Information Search Clusters Factors AmbivalentUncertain Risk Assertively LearnersPatients Avoiders Self-Reliant n=140n=132 n=200 n=153 Information Involvement.502.069 -.275 -.160 Self-Care Orientation-.124.575 -.483.249 Regimen Barriers.170 1.056 -.563 -.365 Information Avoidance 1.167 -.603 -.327 -.121 Risk Aversion.239.056.302 -.664 Question- Asking.013 -.163 -.542.838

15. New Role for Pharmacy Message Tailoring –New “diagnostic” tools? Feedback Provider (Compliance Coach) –Computer records to measure refill compliance Financial Barriers –Can this be provided through manufacturer –mass customization? - privacy favors Pharmacy –Pharmacist user fees?

16. New Role for Pharmacy (2) Location for services: –in pharmacy (face to face) –in central location (mass customization) Activity –initiator or responder to patient requests –passive or active service implementation

17. Health Education and Marketing Health Education: –combination of interventions to change behavior (info transfer) –select by “what works” focus on trials to establish efficacy Marketing –facilitating equitable exchanges (2 way flow) –select by communications goal focus on efficient resource use

18. Marketing Perspective Health Behavior Change is more likely if: –people are involved with healthcare decisions educate and empower patients –people actively plan how to comply planning helps overcome barriers –health professionals teach and explain treatment people do what MDs and RPhs tell them to do 3 Inverse Relationships

19. Behavior Change Low InvolvementHigh Involvement Persuadable (weak messages)

20. Ease of Adoption Thought/Planning Behavior Maintenance

21. Complex Messages Frequency/ Reach Behavior Change

22. Marketing Insights People Change Behavior –when it is easy –when they want to –when it serves their needs/interests People Maintain Behavior –when they internalize beliefs/culturally driven Population Interventions: Cost-effectiveness Targeting/Relationships/Market tests

23. When is 7% change successful? Health Education –significantly better than control –depends on sample size Marketing –major success –define in terms of $$ made, share of market, meeting projections

24. Relationship Era TimeEraAttitude 20’s ProductionA Good Product Sells Itself 50’s SalesCreative Advertising 80’s MarketingFind a Need and Fill it 90’s RelationshipLong-term Relationships

25. Pharmacy Pharmacy as Cultural Change Agents –technology, cross-(sub)cultural, dramatic events –intercept strategies for nonsearchers –tailoring interventions Take advantage of relationships –database marketing How to make it pay?

26. Why Pharmacy? Credibility (Expertise and Trust) –Decision making - Framing Accessibility Close to the Consumer –understand people’s interest Existing relationships –keep info private

27. Segmentational Bases Demographics- age, gender, literacy Disease- severity, stage, timing Geographies- location, Prizm characteristics Psychographics- Customized AIOs, VALS Volume- % consumed, concurrent therapy Outcome- responders, compliers, QoL Benefits Sought- motives for therapy, info

28. Implications for Pharmacy Credibility Economics - little face-to-face –lost opportunity - OBRA ‘90 New Switches –renewed call for 3rd class of drugs Nutrition Supplements

29. Historical Perspective “Let no physician teach the people about medicines or even tell them the names of the medicines, particularly the potent ones, such a purgatives, opiates, narcotics, abortifacients, emetics or any other which are particularly dangerous: for the people may be harmed by their improper use. This under penalty of forty shilliings” - Royal College of Physicians, 1555

30. Why Advertise to Consumers? DTC Promotion Patient MD RPh Manufacturer

31. Objectives Why advertise to consumers? How is consumer marketing different? What role does FDA play? What will be the ultimate effect of DTC?

32. 8 FDA Concerns Reminder/Institutional Implied Claims Disclosure Adequacy Contextual Fair Balance Limits on Effectiveness Overall Fair Balance Unsubstantiated Claims Distractions “RID the CLOUD of DDMAC Response”

33. DTC Considerations Hot, Hot, Hot –FDA Guidance relaxes TV disclosures –$800 mil in 1997, $1.3 bil in 1998 Multiple Media –TV, magazines, internet, professional distribution, direct mail, outdoor Different Challenges and Still Learning FDA Very Sensitivity to TV: 11 of 20 DTC ads had an FDA letter

34. What Evidence Suggests: Hypotheses DTC increases MD visits (Pravacol) DTC increases patient requests for drugs People want risks but info may be confusing Physicians still don’t like it (fluid) –MCO hate DTC Risk information may be problematic –may also detract from benefits Additional disclosures may be problematic –information overload, supers have min impact

35. What Evidence is Needed: Too Early to Form Hypotheses How are TV claims interpreted? –Uses / risks / info availability How prices/costs/liability will change? Impact on consumer as influencer, user Cumulative effects (trivialization) What is a “positive/negative” outcome? –Eye of the beholder, consensus needed –Need research agenda

36. Truthfulness, Balance, Disclosure Roth: –1/3 of ads lack fair balance (unclear what definition was used) General Concerns –Multiple streams of info (see pictures, hear/see words, hear background)/ Limited take away (only 49% of supers are comprehended) –Explicit and Implicit Claims –Limited internal “context-availability” Disclosure as a remedy?

37. Future of DTC More, More, More –Patient as central in future marketing –Marketing as part of drug development Mixed Media –campaigns designed to “move through process” Pharmacists as Implementers –passive or active role?

38. Audience Evolution Information Hungry Segment –Remains Stable for 2 Decades (about 12%) Heterogeneous Elderly –Multiple Meds –Aging Boomers –More willing to question HCPs –Service Directed