Making sense of it

Deciphering health economic messages is no easy task, but it is vital that marketers make sense of them

There is, at present, a cornucopia of conversation about how closer cooperation and more explicit communication between pharma and the NHS will pay off for all stakeholders in health. Marketing is being encouraged to focus on positioning companies as transparent partners, making the healthcare system work better and improving everyone's well-being by result. Talk abounds of integrated care pathways, practice-based commissioning and newfound mutual understanding and trust. Yet, at the core of all that is proposed and projected sits a popular adage. The business of providing healthcare is, in part, precisely that - a business; and in business, as payers in the NHS will testify, money talks.

Indeed, its voice will always be audible because if the finances are not in order, business simply cannot happen, regardless of a product's quality. Pharma companies are, of course, intimately acquainted with the threats posed by mounting cost pressures in the domestic and international markets. Stressors include the relative reduction in NHS funding, changes in NHS liaison requiring investment of resources, increased use of newly genericised products, plus an unremitting pressure to deliver near-term value hikes for shareholders. As the scale of these stressors escalates, it is more vital than ever that the industry's marketers ensure clear communication of the health economic arguments to the wealth of decision influencers involved now, both within and outside the health service.

The key is to understand that each of the many decision influencers, or 'payer-stakeholders', with responsibility for calling the shots on medicine usage, reimbursement, and inclusion on formularies or in healthcare plans, has his/her own set of centrally-defined, locally-interpreted objectives. According to John Fanshawe, co-principal at specialist healthcare value communications consultancy, Medaxial: Pharma relies on the work of HEOR (health economic and outcomes research) departments to understand these agendas, and make appropriately attractive value cases for its products. Yet, the value argument developed by a health and outcomes economist for any particular medicine is not - to understate it greatly - an unsophisticated proposition. The Magna Carta, by comparison, is a straightforward read versus some of the heavyweight health economic discussions developed by HEOR personnel.

Under the new regime - where the NHS is driven to pay for health 'gains', rather than pills - it will seek, more ardently than ever, to understand from pharma how its products will add value, cut costs (or achieve whatever goal a particular payer-stakeholder strives for). The problem is that the intricate and convoluted HEOR value case does not provide marketing with a 'workable' basis from which to communicate these benefits.

There are issues for companies in the way they choose to convey these messages and whether their salesforces are comfortable, notes Professor Adrian Towse, director of the Office of Health Economics. There is, inevitably, a tension between the 'scientists' and the marketers. I guess that companies have been managing that issue on the clinical side, but it's newer and harder to manage the health outcomes messages, mainly because people in marketing need to understand both the messages and the studies on which they're based - a knowledge set they're probably not routinely familiar with.

The irony is that pharma already has the information sought by NHS payer-stakeholders, yet is often unable to utilise it to maximum (or even any) effect because of the lack of cohesion between HEOR and marketing departments. HEOR people, often academics with incredible commitment and focus, will perceive marketing as merely producing the headlines and 'clinically persuasive' material for the salesforce, without meticulous effort put behind the 'other half' of the argument, Fanshawe notes. Conversely, those in marketing might not agree that rigorous deliberation over Incremental Cost-Effectiveness Ratios (ICERs) and Quality Adjusted Life Years (QALYs) will set their customer's world on fire quite as desired.

The truth is, of course, that both are indispensable elements, though the health economic arguments have never been more central to the success of intelligent medical marketing plans. Having identified them, failure to refine and communicate these 'value benefits' to the right people and in the right way is like choosing the winning Lotto numbers, but not showing the ticket to anyone; just as life looked to be on the brink of improving immeasurably, it was impossible for anyone to verify your worth - and, ultimately, all interest and potential gains were lost.

Joined up communication
Rolls Royce, with its timeless style, has failed to portray its products as particularly affordable to most buyers. It is not impossible, however, for Rolls Royce Motor Cars (or BMW, as some now prefer) to enlighten a buyer to the value of making such an investment, so as to present the financial options that suit the buyer's objectives and limitations.

Ultimately, the product costs what it does and any buyer must be honest about whether a purchase should be made. Yet, certainly, it would be a misdeed if the buyer walked out of a showroom on the basis that the manufacturer did not present the true value of its products with clarity and in empathy with an ability to pay. It should allow the purchaser to make their decision fully informed.

That is not to say that we should equate branded drugs with Rolls Royces, but merely makes the point that a buyer needs to be able to understand clearly why the products are so priced, and how they represent 'value' above and beyond merely the 'cost'. Adding value to the NHS, as a pharma company, can be defined in many different ways, but it is imperative that health economists work on improving the communication of that value, as well as generating the evidence to demonstrate it.

To be fair to the health economists in companies, they're being pushed by the health technology assessment (HTA) boards to be evermore scientifically sophisticated, and for obvious reasons the salesforce also wants simple messages that it can deliver to its customers, notes Professor Towse.

Francis Pang, European health economics manager at Takeda, believes that the path of persuasion for access has become multifaceted, long, intensive and complex, requiring a portfolio of tools. As the demands on budgets have augmented, increasing numbers of decision makers within the NHS at different levels are involved in treatment choices and access to medicines. Therefore, the information requirements have expanded, with health economic arguments required at different levels of complexity. Also, a variety of people within pharma companies are now involved in the delivery of these messages, including sales reps, key account managers and government liaison personnel.

He adds that to deliver health economic arguments effectively, communication between internal stakeholders within a pharma company is just as important as with external decision makers.

Speak my language
The problem can be solved through an appreciation that HEOR tools must be tailored according to the level of the target audience, and that the one-size-fits-all approach is ineffective. HEOR models must be fit for purpose. Sophisticated cost-effectiveness models are really only for submission to health technology assessment agencies, such as NICE, the SMC and the AWMSG, Pang notes.

Pharma must take a more proactive and holistic approach in devising and readying its arguments and counterarguments, insists Fanshawe. Convincing the many payers is the basic issue and companies cannot afford to be passive. They need to be fully equipped to make their case with rigour and sophistication when talking to an HTA, but likewise in an appropriate format for stakeholders in general practice, the hospital setting, pharmacies and also non-NHS bodies, such as the media, politicians and patient/pressure groups.

To ensure no stakeholder overlooks the real value of a drug, to patients, the NHS, as well as society as a whole, pharma firms must strive to maximise the impact of messages aimed at every payer and decision influencer. Key in making an effective and appropriate value case is anticipating potential objections and the development of counterarguments, which should be aligned with a particular payer's ambitions. The box (opposite) highlights a few of the key UK decision-influencers, and includes recommendations in formulating an appropriate value case for each.

Specialist assistance, such as the interactive software developed by Medaxial, is available to help pharma avoid making costly mistakes or oversights. It also aids the creation of tailored health economic arguments and, crucially, enables those in the NHS charged with making spending decisions to defend their judgements. The calculation of costs and outcomes on a local basis offers assurance, and a predictive view of a medicine's long-term value assists in behind-the-scenes discussions within the NHS. Added to this, formulary toolkits and other related materials serve to facilitate understanding of economic arguments by marketing and salesforce personnel, and are adaptable for local and international use.

The healthcare environment is evolving. Only drugs with real differentiation and strong health economic evidence will be able to command premium prices in the market. As prescribing guidelines become more stringent, and with the changing ways in which GP practices are asked to demonstrate accountability, inferior products will quickly be relegated to third or perhaps fourth line treatments, and struggle to sustain viability as a result.

The healthcare system in the UK must become an organisation driven by the value of health 'gain', rather than merely the price of a medicine, Fanshawe concludes. For pharma, while adding value is still essentially the name of the game, communicating the fundamental value of that health gain imbued through the use of a particular product is key to getting a medicine sold in the NHS. In order to do this, one must first know of, and understand, the agendas of the myriad decision influencers, and then present the economic arguments for a medicine in such a format as can be used effectively by the salesforce.

Audience and pre-occupations in the NHS Health economists are most commonly engaged in providing evidence for the National Institute for Health and Clinical Excellence (NICE). However, NICE is one of several audiences making or influencing value-related decisions in the NHS. Others to consider include:

Primary Care Trusts (PCTs)
When it comes to communicating value, there are two main audiences within PCTs.

- Pharmacy advisers' main remit is to control the drugs budget. With a fixed drug budget, extra spend in one area must result in a corresponding reduction in another area. Cost saving is, therefore, key to this audience, and consequently they require a lot of persuading when no obvious cost-saving is portrayed - Clinical leads, however, seek to optimise the management of a therapy area within a PCT. They may be open to an increase in costs if a drug can be shown to improve outcomes. PCTs are under pressure, not merely to balance their budgets, but also to meet government targets and to implement plans such as National Service Frameworks (NSFs) and the NHS Cancer Plan. Be it smoking cessation, breast cancer or obesity, PCTs are expected to turn government initiatives into spending allocations and, as such, may be open to more politicised arguments.

Hospital managers
Payment by results makes hospital managers more receptive to arguments that demonstrate an increase in the speed or success of treatment, expressed in terms such as earlier discharge from hospital or reduced complications from treatment.

Hospital pharmacists
As with pharmacy advisers within PCTs, hospital pharmacists usually have a fixed drugs budget. While they work in an outcomes-oriented environment, they remain preoccupied with cost.

Formulary committee members
With a mixed make-up of clinicians, pharmacists and managers, formulary committees seek to balance cost, outcomes and efficiency. Consultants are key influencers though other stake-holders, more focused on the drugs budget, may have the final say.

... and finally
'Value' means different things to different stakeholders. The brief outline above is a snapshot of some of the stakeholders within one healthcare system. Working internationally only increases the challenges of successfully communicating value. It is essential to provide value arguments that address stakeholders' concerns and preoccupations and talk in language they can understand.

The Author
Dave McGregor is a writer working with Medaxial