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Patients are more knowledgeable and more involved than ever before in healthcare decisions.

Patients are more knowledgeable and more involved than ever before in healthcare decisions. But according to Reinhard Angelmar, the Salmon and Rameau Fellow in Healthcare Management and Professor of Marketing at INSEAD, empowered patients are having an impact before a drug even makes it to the market.

Patients can influence decisions at every product lifecycle stage, said Angelmar at the recent eyeforpharma SFE Europe 2009 conference.

Angelmars presentation emphasized that patients are becoming more empowered, which makes the push model of marketing less effective. He made a case for pharmaceutical companies to become more patient-centric where the patient is boss. He also emphasized that new EU regulations in the works may allow more effective direct interactions with patients.

It Starts with Research
Patient empowerment starts with research, said Angelmar. Patient power is reaching back into the R&D process deeply. As an example, Angelmar described how breast cancer patients in the US were instrumental in diverting funds from the Department of Defense to breast cancer research. In a number of countries, patient organizations are represented in government research funding processes.

Angelmar cited several cases in which patients influenced one or more stages in a drug products lifecycle, including research, development, market authorization, market access, or in-market stage. In one example the approval of Novartis AMD drug Lucentis Angelmar claimed that patients were instrumental in getting Britain's cost-effectiveness watchdog NICE to change its position and approve the drug for wider use than originally intended.

Last, but not least, said Angelmar, when products come on the market, patients may have a role in what brands get prescribed and whether or not they comply and persist with the treatment.

Degrees of Patient Empowerment
Angelmar discussed several models representing different degrees of patient empowerment, or lack thereof, during the treatment process, ranging from a gods in white coats model, where basically the physicians does everything, to the autonomous patient model, where doctors no longer are seen as capable of determining what will benefit their patients. What do we mean by patient empowerment? Angelmar asked. Does it mean going all the way to the autonomous patient model? Would that be good for the industry? Im not sure.

Where are the opportunities for patients to take charge of their health? For $399, you can order a genetic analysis and learn if you have a predisposition for a genetic disease. Sergi Brin, Google co-founder, discovered that he had a genetic code linked to Parkinsons disease.

Technologies that did not exist until recently, said Angelmar, are now within our reach. And with prices following the trend in consumer electronics and dropping rapidly, access is on the rise.

When consumers find out they have a medical condition or predisposition for developing one, they decide how to get treatment. In Germany, the majority [of consumers] take natural remedies first, noted Angelmar. When that doesnt work, he says, many go to the pharmacist to purchase non-prescription OTC medicines.

European patients have a broad range of sources for health information, said Angelmar. More and more people in Europe are consulting the Internet about their health issues. According to National Cancer Institute statistics, the majority of US cancer patients turn to the Internet first when they wanted information. And Healthcare professionals, rated the internet as a preferred source when there was a strong need for information about cancer.

The latest data from Manhattan Research reveals that 66% of all US adults went online for health information in 2008 and 66% of these (or 51% of all adults) searched for drug information online. If you are working in certain franchise areas, said Angelmar, you will want to know the role that the Internet and other information sources play for your patients.

Is Europe Online?
According to Manhattan Research, 150 million European adults went online for health information during 2008 and 70 million adults sought pharmaceutical information online. When health issues occur, online European consumers are more likely to first turn to the internet before going to their doctors. But only 47% of European online adults went searched online for product information compared to 66% in the US. This is probably because of regulatory constraints, said Angelmar. Theres a possibility that these constraints in the EU will be changed, he noted.

When patients in Europe do finally go to the physician, what influence do they have over the medication they are prescribed? A survey of German patients (Typologie der Wunsche, 2008) found that a majority will ask their physicians to prescribe medications that they know about or that they have had a good experience with.

Of course, noted Angelmar, in the US where there is consumer advertising, one of the goals is to get consumers to request your brand. Differences are seen, depending on the condition, however. For symptomatic conditions such as ED and ADHD that easy to self-diagnose, Verispans Physician Drug & Diagnosis Audit finds that patient requests for specific drugs are more frequent than for drugs that treat asymptomatic, difficult to self-diagnose conditions such as diabetes and hypertension.

But the likelihood that a physician will honor a request also varies by condition. This is primarily due to competition. There are, of course, many treatment choices for diabetes, hyperlipidemia and hypertension, but fewer options for ED and ADHD.

The key point, said Angelmar, is that patient empowerment and behavior varies greatly across conditions and it is very important to know how your patients behave, how empowered they are, and where they look for information.

Compliance and Persistence
Once patients get the prescription, however, all of the power is in their hands. They decide whether they get the prescription filled, if they take the medication, and whether they persist with the treatment. The extent of the challenge of patient compliance and persistence is well documented.

The power of patients is illustrated well by an examination of Avandia. When a study was published in the May 21, 2007 issue of the New England Journal of Medicine that seemed to show an increase in myocardial infarction and death due to Avandia, primary care physicians and endocrinologists were somewhat skeptical, but their patients were very concerned. What happened was very bad for Avandia, noted Angelmar. Within a week, Avandias share of the dynamic market dropped from about 15% to 5%. I think that tells us something about patient power.

The overall picture shows quite a lot of patient empowerment all the way through the patient journey, Angelmar summed up. The drivers of patient empowerment, Angelmar summarized, are:

OPPORTUNITY: Opportunities for patients to control decisions
Patient advocacy organizations
Patient rights
Regulations regarding patient representation and involvement
More choice, e.g., Rx to OTC switching
Easier access to Rx medicines (e.g., internet pharmacies)
Easier access to health and medicines information
Decision aids
Media interest in health and pharma

ABILITY: Patients ability to control decisions in a way that improves their health
Health and medical knowledge
Patient skills: expert patients

MOTIVATION: Patients motivation to control decisions
Interest in health
Desire to be in control
Cost sharing raises motivation to get value for money

Patient empowerment could be a threat to the classic pharma push model, where product is pushed to the end user the patient - through a physician-centric model. With increasing patient empowerment, pushing will be less effective. The pressure of payers on physician prescribing habits will also make the push model less effective.

The Patient-Centric Organization
What can pharma companies do? One option, said Angelmar, is to think push-pull like [is done] in the consumer goods markets - getting patients to pull brands through the channel and request products from physicians and payers.

Another option, he says, is to look at this as a cooperative game, where we are all partners with one common goal, which is not to get patients to take our pills, but to improve patient outcomes. If we refocus on patients and patient outcomes, then we become partners. If we, as a pharma company, develop unique expertise in decoding the behavior, needs, motivations of patients, then this unique knowledge can be the basis of what we do. And we can also use this knowledge to help healthcare professionals and payers to put into place programs that achieve better patient outcomes.

Angelmar says this requires transitioning to a patient-centric organization where the patients are really in the center, where all of the players in the healthcare system are seen as supporting the patient and all of the internal functions then have as their mission to develop programs to achieve good patient outcomes.

He points out that the consumer goods industry uses this model. At Proctor and Gamble, for example, the mantra is The Consumer is Boss. P&Gs best secret weapon is consumer market knowledge (CMK). CMK competency within P&G builds the company's renowned gut-level understanding of "what consumers think and what they want. It champions the voice of the customer within P&G.

Pharmaceutical companies have experience with physician-centric models where they can be said to have physician market knowledge. Medical Science Liaisons (MSLs) usually fulfill the role of championing the voice of physicians within pharma. Unfortunately, however, pharma is lacking when it comes to consumer-centric champions who understand what consumers think and want.

European Union Barriers
Angelmar suggests that pharmaceutical companies should use the same customer relationship tools on the consumer side as it uses on the physicians side. Personalized interactions with patients, admits Angelmar, is not as easy in Europe because of regulatory constraints.

Angelmar notes that EU policies on communicating with patients prohibit consumer advertising of Rx medicines. Advertising is defined as any form of door-to-door information, canvassing activity or inducement designed to promote the prescription, supply, sale or consumption of medicinal products. Excluded from this definition are labeling and package leaflets, correspondence answering questions about particular medicinal products, factual, informative announcements and reference material (e.g., pack changes, adverse-reaction warnings, trade catalogues and price lists), and information relating to human health or diseases.

Angelmar noted that the interpretation of what is allowed differs from country to country within the EU. In some countries, for example, even labels and package leaflets are considered to be advertising, unless they accompany the prescription.

For EU consumers, this results in variations in information access for identical products depending on the country in which they live, travel, or seek healthcare, as well as their access to the internet and their (English) language skills. If you know English, said Angelmar, you can have all the information you want. If you dont speak English, forget about it!

Angelmar also pointed out that there are no restrictions for other stakeholders or individuals to comment on medicines for which they have no responsibility or requirement to demonstrate their competence. Consequently, its often easier to find product information on questionable and non-EU websites than on the manufacturers website.

There is an EU Commission proposal attempting to relax some of the constraints. For example, allowing package leaflet information to be presented in a different way, which Angelmar says could mean in a more patient-friendly language. If this proposal were to go through, says Angelmar, the industry will be in a much better position to become patient centric.

Will it happen? Angelmar pointed out that trust is something that the industry lacks badly among some key lobbies, especially, consumer organizations. Monique Goyens, director general of the influential European consumer organization BEUC had this to say: "The proposal is just a disguised way of giving pharmaceutical companies greater flexibility to provide the information they want on prescription medicines directly to the public, namely direct-to-consumer communication strategies - the goal of which in our view is to boost sales it is imperative for the Parliament and Council tonip this proposal in the bud.

While Angelmar focused mostly on the EU, much of what he said has relevance to the US as well. Regulations in the US, while less strenuous than in the EU, have often been cited as an obstacle to pharmaceutical companies ability to become more patient-centric. However, regulations or no regulations, pharmaceutical companies must adapt internally if they are to move toward a patient-centric model.

John Mack is Editor, Pharma Marketing News
www.news.pharma-mkting.com