NATIONAL ANALYSTS WORLDWIDE - Calling the Shots: New Customer Roles in a Reshaped Healthcare System

Uploaded by NationalAnalysts on 04.04.2011

Hello. I’m Debbie Kossman, a Senior Vice President in the Healthcare practice at National
Analysts Worldwide in Philadelphia and Chair of the Board of Directors of the Pharmaceutical
Marketing Research Group, the PMRG. Anniversaries are wonderful celebrations of
history, experience, and accomplishment, but they’re also a time to reflect and look
forward. A hundred years ago, when National Analysts Worldwide was founded, more people
died of infectious disease than of any other cause. There was no penicillin; there were
almost no vaccines. And fifty years ago, when PMRG was founded, hypertension went largely
untreated; the discovery of DNA was only eight years old; and sequencing of the first human
genome was over 40 years in the future. It’s humbling to imagine what a poor job of forecasting
the healthcare future any of us might have done back then if we’d been pressed to project
the state of medical affairs in 2011. But looking ahead is an essential part of
what we do in our business – however challenging it may be – and as we look ahead to the
next decade, there are three predictions we can make with conviction. The trends we see
have less to do with which new therapies will emerge than about how care will be delivered
and by whom – and about who will be responsible for calculating value.
First, it’s a virtual certainty that clinical practice guidelines will be adopted and refined
to achieve the goal of standardizing patient care across practices and geographies. Second,
we can easily see that the shortage of primary care physicians will require that nurse practitioners
be given greater clinical responsibility and autonomy. Third, consumer empowerment will
set the stage for consumer responsibility: patients will have to spend more of their
discretionary income on health services, which will impose on them the obligation to decide
what matters and how much it’s worth. Each of these three changes will accelerate
in the next 20 years and each has implications not just for how providers do their jobs,
but equally, for how marketing researchers do theirs. Here’s why.
Let’s start with increasing reliance on clinical guidelines. The lack of standardization
of care in the US has led to shocking variations in treatment outcomes and equally shocking
cost differentials, to the point that in some places, and for some conditions, more money
is spent to deliver worse outcomes. Only reluctantly do we give up our autonomy in this country,
but oncologists – for whom the stakes and challenges are especially high – were early
practitioners of evidence-based medicine and have already embraced clinical guidelines.
They are the vanguard of the future. The move to optimize and standardize other
areas of patient care gained momentum this past December when the Dartmouth Institute
for Health Policy and Clinical practice announced a collaborative initiative among seven premier
US healthcare organizations to share data on outcomes, quality, and costs.  The participants
are: Dartmouth-Hitchcock, Cleveland Clinic, Denver Health, Geisinger Health System, Intermountain
Health, and the Mayo Clinic – organizations which together manage 10 million patients. 
They’ll be focusing first on a handful of conditions associated with rapidly increasing
costs and wide variations in quality and outcomes across the country. Among them are asthma,
diabetes, heart failure, and depression. The collaborative aims to develop best-practice
models that will, in their words, “impact the clinical care of patients across the country
by disseminating these models quickly and working with providers and health systems
to adapt them to local conditions.” What does this trend mean for our industry?
The battle for product success will increasingly be fought before a shrinking audience of decision-makers
who control outcome studies and write the clinical treatment guidelines – guidelines
that will be followed by front-line providers and used by payors to set reimbursement policies.
This means that the masses of community practitioners who implement those guidelines will become
increasingly irrelevant as marketing research respondents. The treatment plans and product
choices they implement will more faithfully follow clinical pathways they’ve had little
role in creating. There will, of course, always be some room
for interpretation by site-of-care decision-makers because clinical situations can be ambiguous,
and patient “portraits” not always crisp. But leverage with end-users will diminish
as the role of brands is established earlier and elsewhere.
What about our second prediction: that the shortage of primary care physicians will require
that nurse practitioners assume greater clinical responsibility and autonomy? How will this
affect the clinical and commercial landscape? There’s rarely a clearer perch from which
to make predictions about the future than demographics. And the demographics are undeniable:
both the number of people aged 65 and older, and the percentage of the US population they
represent, will increase substantially between now and 2030. Chronic illness affects over
80% of older adults and consumes the greatest resources. Almost a quarter of older patients
have five or more chronic conditions, regularly visit 13 different physicians, and fill over
50 prescriptions annually. The demand for primary care, coordination of care, and elderly
care is growing rapidly. We also know that there’s already a shortage
of primary care physicians. The average PCP today carries an annual caseload of approximately
2,400 patients, requiring physicians to see patient after patient throughout the day at
a breakneck pace. That makes “throughput” the natural solution to two problems: rising
volume and declining reimbursement But both trends – the physician shortage and the
attempts to curtail the cost of care – mean that even though there are many more diagnostic
codes and therapies than ever before, the average patient spends far less time with
his or her physician than at any time in the past. Far less time in which the provider
must do far more. To meet the demand for primary care in 2030,
each PCP would have to see 33% more patients than today. To avoid that, we will need 40,000
more physicians than we expect to have. Otherwise, 95 million patients will go without access
to a physician simply because of the lack of providers to handle them. And the problem
can only get worse once we bring another 32 million uninsured patients into an already
stressed system. Over the past 20 years, the number of NPs
per capita in the US has risen seven times faster than the number of MDs. In 2011, sixteen
states and the District of Columbia allow nurse practitioners to practice and prescribe
independently of physicians, and 28 more states are now considering regulations that would
allow NPs to practice a full range of responsibilities. Within the VA, Kaiser Permanente, and Geisinger
Health Systems, the expanded role of NPs has been linked to improved quality and patient
satisfaction, as well as to cost reduction. In underserved urban and rural areas – and,
importantly, in the rapidly expanding setting of retail clinics – NPs play an especially
prominent role in the provision of primary care.  Training programs across the country
are moving toward curricula that will prepare NPs in gerontology as well as adult health,
to ensure that graduates are ready to contribute to the care of older patients.
  It’s difficult to see how the role of nurse practitioners will not expand given
all of the pressures on a system that seems over-priced, over-burdened, and under-resourced.
This is already true in selected states for specific treatment settings such as retail
clinics; school-based health centers; community mental health clinics; and nursing homes.
Going forward, NPs will increasingly be involved in specialized therapeutic areas such as neonatal
medicine, anesthesiology, intensive care, diabetes, and oncology. The implication for
marketers and marketing researchers is very important. It means that even as we anticipate
long-term shifts in marketing focus from front-line practitioners to guideline oligarchs, we will
need, in the near-term, to include NPs as marketing targets and research respondents.
That brings us to our third prediction – the shift in responsibility to patients, who will
be asked to pay more out-of-pocket and will therefore need to play a greater role in assessing
price-value. In the past, the industry has paid nodding
attention to patient willingness to pay, but going forward, that issue will need to become
a central concern. Imagine a scenario in which a new therapy for relapsed or refractory metastatic
cancer delivers a two-week increase in median survival, with responders living about six
weeks longer. If patients are unwilling to pay their share of this therapy, there will
be little point in investing in its development. A benchmark survey on that issue conducted
by National Analysts Worldwide just a few years ago confirms that oncologists – who
are ahead of the curve in so many ways – are increasingly implicating patients directly
in this cost-benefit calculation. The UK’s National Institute for Health and
Clinical Effectiveness – NICE – aspires to unflinching application of cost-effectiveness
hurdles for new therapies, and it’s a harbinger of things to come in this country. As stewards
for a larger system, government authorities and insurers are clearly less motivated than
the patients they cover to “green-light” expensive and heroic therapies. Yet the evidence
suggests that patients themselves may make tradeoffs that surprise us once they have
less money in their pockets and more of it is needed to pay for retirement and healthcare.
We already know that at the pharmacy counter, a $10 co-pay difference easily tips the balance
from a Tier 3 to a Tier 2 medication. We also know that out-of-pocket costs for more expensive
therapies can discourage some patients from taking them at all. As marketing researchers,
we will have to sharpen our tools to allow us to evaluate consumers’ willingness to
pay – for health insurance to cover specific contingencies and therapies whose benefits
are difficult to assess in personal terms and whose costs compete with other things
that families value just as much. The market research industry has had far more experience
developing intent-to-purchase modeling algorithms for appliances and snack foods than it has
in modeling patients’ intent to purchase costly, life-saving therapies. We need to
put those tools to the test to determine how well they approximate real-world behavior
when the stakes are far higher and the tradeoffs more emotionally complex.
A century ago, in 1911, the term “health insurance” was coined when the British passed
their National Insurance Act, the same year our own firm came into existence. In 1961,
the year PMRG was founded, an NIH scientist, Marshall Nirenberg, proved that the triplet
code is the way information to make proteins is encoded in DNA. Fifty years later we’ve
only begun to tap the therapeutic possibilities of that discovery, and yet the same 50 years
has taken us with unsettling speed from boundless economic potential to daunting success hurdles
and somber austerity. Marketing researchers are the people in this
industry who need to see around all the sharp corners. And like the healthcare system itself,
the system we serve is running out of resources. That means we’ll need to be vigilant, thoughtful,
and creative in order to ensure that our research remains relevant and trustworthy. Even 10
years from now.