Understanding new influences acting on healthcare practitioners: Gaining a 360-degree view of customers

By Tom Haskell and John Moran, IMS Innovation Lab

Increasingly, prescribing decisions are influenced by new and dynamic factors that did not exist only a few years ago: peer-to-peer electronic media, health plan-mandated prescribing algorithms, and patient-led treatment strategies. To improve their sales and marketing effectiveness, pharmaceutical companies must understand which factors are influencing which physicians locally, and then change their promotional strategy, messaging, and product positioning accordingly. This understanding becomes even more important as companies transition to new commercial models, such as with a regional operation.

This article identifies the shifting influences affecting prescribers' medication choices. We present an approach for recognizing which influences are most important, along with implications for optimizing local commercial strategies. Finally, we recommend performance metrics that reflect the new prescribing influences. The result is a 360-degree view of customers that will drive physician characterization and highlight the best way to address each segment. To support these changes, we provide a comprehensive, implementation framework.

Today's Emerging Influences

New commercial strategies must take into account the growing number of new and different influences acting on healthcare practitioners (HCPs) and their decision process. Although these influences are diverse and complex, they can be grouped into three general categories:

1. Managed care-driven
2. Patient-driven
3. Technology-driven

Usually, the influence of managed care is discussed in terms of generic usage, yet managed care also impacts the choice of branded drugs having no generic version. The decision to prescribe a Tier 2 over a Tier 3 medication may happen at once (if the prescriber is closely attuned to the patient's insurance provider), or over time (if the prescriber hears complaints from multiple patients on the cost of the Tier 3 drug). In addition, prior authorizations can cause dispensing delays, frustrating the patient and leading to poor compliance or an unfilled prescription.

Patients continue to exert their influence on prescribing, most commonly by making requests of physicians based on Direct-to-Consumer promotion. Patients with chronic conditions, especially, are relying on disease sites, general Internet research, or online patient communities for therapeutic advice. While the veracity and value of that advice varies, patients are nonetheless exerting a stronger voice in therapy and medication decisions.

Physicians, too, are relying more heavily on the Internet for information. Most medical journals are now online as are many CME courses, and the use of e-detailing is on the rise. Physician-networking sites, such as Sermo, have also sprung up, allowing physicians to discuss different therapies with one another.

Recognizing and Prioritizing New Influences

Understanding how these new influences will play out is important not only to improving the brand's customer focus, but also to ensuring the success of new commercial models. Selecting and deploying activities locally using predictive analytics can support new operating models by driving stronger customer relationships, optimizing the P&L through more efficient brand spending, and improving brand utilization. However, with this opportunity comes greater complexity. Using traditional promotion channels differentially across regions is already a complex undertaking. Adding new influence channels to the mix can become unmanageable for a regional business unit.

To effectively guide either regional units or the national franchise, the headquarters' commercial analytics and market research functions must vet new influence sources-qualitatively as well as quantitatively-and offer specific deployment recommendations. Recommendations should be made in conjunction with the regional business unit's strategy and operating approach. For example, a region focused on obtaining preferred status for second-line therapy will benefit most from deploying channels that educate HCPs and payers on patient flows and treatment patterns.

Determining how much to invest in which channels is now a more complicated task that involves asking, "which influences act where, what level of support should be re-allocated from traditional channels, and how should investment performance be measured?" These types of questions are strategic, rather than quantitative, and can only be answered with customer insights.

The new influences will differ in the duration of their impact, and sorting out the high-value activities from the "trendy" ideas is the challenge. What is more, these various influences do not impact HCPs uniformly. New influences that are acting aggressively on younger Primary Care Physicians in the Pacific Northwest may be insignificant for middle-aged surgeons in the Southeast. Figuring out the rate and pace of impact regionally and by specialty, therefore, poses an opportunity to maximize brand performance in the near and long term.

Assessing the Impact of New Influences

In general, there are three types of measurement methods for assessing the impact and importance of the new influences: HCP-level analyses, regional-level models, and channel-level models. There isn't one right way to assess an influence; often, multiple models are required to best explain prescribing impact.

HCP-Level Analysis

HCP-level analysis is quantitative in nature and only possible when the influence can be attributed to individual physicians or groups of physicians. The number of HCPs that are exposed to, or actively involved in, new influences can be identified through primary research, from which the HCP-level analysis can be developed. Some companies are including questions about exposure to new forms of promotion on their attitude, trial, and usage or message recall studies. In some cases, research on sales force effectiveness is also capturing exposure to different influences beyond the sales force.

Promotion and education influences such as e-detailing, patient coupon usage, and contracting events are readily analyzed by comparing the prescribing behavior of test and control groups. If the influence takes place over a period of time rather than as a one-time event, time-series regression analyses similar to promotional-mix modeling can be applied. Some commercial analytics organizations have started to include new forms of promotion, such as the effect of managed care, in their core modeling processes to determine promotional mix.

Often, models produce results that are not intuitive. For example, in one study of coupon usage among patients in a specialty-focused disease area, IMS found that certain coupon types and offers significantly influenced the follow-on adherence of patients. It was reasonable to assume that couponing had some impact on new patient share, but the study also revealed how specific coupon, disease, and physician factors come together to raise patient adherence. This finding has significant implications for promotion planning, particularly in assigning Return-On-Investment (ROI) variables, since ROI models don't typically account for the "lifetime value" of the patient brought into the franchise.

Armed with this kind of information, commercial teams can use physician and patient characteristics as predictors of utilization and then focus their limited coupon resources where they will be most beneficial.

Regional-Level Modeling

Regional-level modeling incorporates HCP-level analysis-specifically in the quantitative test and control or time-series techniques discussed above. But regional-level modeling is also a strategic framework that enables leadership to gain a more comprehensive view of the likely future impact of influences working together. Figure 1 represents the overall, four-step approach.

Figure 1. Strategic regional assessment model: e-detailing

Channel-Level Assessment

Channel-level (or influence-level) assessment involves tracking HCP interest in, and satisfaction with, a given influence. Primary research is integrated with new-to-brand prescribing metrics to identify how changing perceptions affect prescribing decisions. In one example, a specialty brand tracked customer ratings of brand value to evaluate the impact of alternative forms of promotion, as well as of the sales force. Such an analysis produces a comprehensive view of how the influence or channel is impacting satisfaction, loyalty, and prescribing. The results are used to prioritize program efforts, or to implement region-specific programs that increase customer value in lagging geographies.

Restructuring Commercial Insight Activity to Measure Influences

To understand how new influence sources affect HCPs, companies need to develop a richer dialog with customers through primary research and rep-HCP interactions. They can free up dollars and capacity to support such higher-value research by migrating certain traditional, primary-research activities to secondary data sources. Specifically, quantitative research normally conducted via large-scale, primary- research studies on awareness, trial, and usage can be done through secondary-based customer tracking studies.

For example, by studying the behavior of physicians across therapy classes, the importance placed on brand attributes can be strongly inferred. And, studying a physician's specific patient cohorts over time reveals much about how HCPs are influenced by reimbursement, detailing, special events, patient factors, disease severity, co-morbidities, and many other characteristics.

Adopting New Performance Metrics

A view of current influences should be tied to an assessment of the extent to which brand choice is modified. Influences can then be prioritized to drive commercial strategy decisions /choices.

Traditional metrics such as brand share and volume can be applied to some, but not all, new influences. Others require new performance metrics.

The following questions are being tested in industry research to better characterize the new influences and to set up more insightful metrics of brand performance:

1. How does the influence affect the strength of the relationship between the prescriber, company, and brand?  Can relationships with HCPs be strengthened by indirect influences, such as social media?  Regular assessment of relationship strength and corresponding value delivered is critical for brands operating under new commercial models.
2. How does the influence support or contradict the brand's value proposition?  One metric to consider is believability of the brand's message in light of new influences being exercised. For example, peer-to-peer experiential dialog via the Internet may substantiate or significantly weaken the brand's claims. A metric of "customer alignment" is required and can be quantified by mining the dialog.
3. To what extent does the influence help or hurt company communication and education efforts, including personal promotion?  The emergence of widely accessible technologies for sharing information has the potential to spread incomplete, biased, or worse, inaccurate information, which may change the nature of discussions between reps and HCPs. Field organizations must understand and address misconceptions and objections that develop more quickly in today's highly-connected environment.
4. At the heart of today's influences are two related goals: containing costs and understanding comparative effectiveness. Measurement programs need to consider both these drivers to effectively evaluate brand performance.

Measuring the impact of a pharmaceutical brand on patient outcomes and cost containment is still in its infancy as a commercial business practice. However, new metrics about cost and value are taking shape, even if they are not yet on the brand's balanced scorecard or performance dashboard. A good starting point for using new metrics is to assign them only to new influences initially. They could then be expanded to traditional promotion and education activities.

Four metrics of performance can be used to evaluate the role of new influences on brand performance:

1. Penetration: increase in the number of active presribers of the brand  
2. Treatment Rates: increase in patients diagnosed and treated
3. Disease Intervention Rates: decrease in the time to assess and treat first-line failures
4. Patient Compliance/Adherence: increase in patient compliance with regimen

Framework to Implement Successfully

Successfully evaluating, prioritizing, and deploying commercial activities focused on today's new influences demands a well-defined, cross-functional commercial process. Figure 3 summarizes the overall process for addressing new influences.

The first step is expanding (or at least re-deploying) resources for measuring the extent of HCP exposure to influence sources and the resulting behavioral change. Commercial analytics teams can begin by creating an influence map indicating the corresponding sources of data available.

New measures can be integrated into an existing customer research activity, or completed through additional programs. Using existing research programs offers cost synergy, but limits the scope and drill-down capabilities. Involving customer-facing team members is highly useful in interpreting and prioritizing insights.

As a second step, brand managers should look for gaps between the findings and their brand strategy and promotion plans. Within the brand plan, it is helpful to include a list of major influences acting on HCPs and to plan a set of programs against these influences. Each year, the brand plan should have a few promotional "R&D" elements that offer more insight into the impact of new influences and how well the brand team is addressing them.

Once influences are identified, prioritized, and included in the brand plan for observation and future action, the third step-tracking and assessing impact-can begin. This involves adding a few Key Performance Indicators (KPIs) such as brand penetration, productivity, and adherence on the brand dashboard to monitor the spread of the influence, and to track how well the brand is responding to these influences.

Particularly as companies move to new commercial models, it will become important for them to have a 360-degree view of their customers and all the factors influencing their prescribing decisions. With the help of predictive analytics and new measures of impact, they can select and deploy new influencing activities locally. This will strengthen their relationships with healthcare practitioners, optimize brand spending, and improve brand usage.