Untapping the unconscious: the next revolution in pharma marketing

pharmafile | September 9, 2013 | Feature | Manufacturing and Production, Medical Communications, Research and Development, Sales and Marketing |  Strategic North, allman, pharma marketing, sharman 

There has been a lot of doom and gloom about the pharmaceutical industry in recent years, with drying pipelines and regular restructures. Working in the industry, it is easy to find it all a bit hopeless as we watch our beloved world ‘go to the dogs’.

However, these changes can be seen as an opportunity. Yes, the days of the big blockbusters are gone, but working in marketing with products that fly off the shelves does not present the same intellectual challenge that a more limited pipeline, with increased generic competition and smaller healthcare budgets, presents.

Increased competition in pharma marketing has caused it to evolve over time as more weapons are added to the armoury to better compete. This arms race of pharma marketing has been fought first through the rational and then into the emotional realms of persuasion.

As an example, take a look at one of the world’s biggest selling depression drugs – Otsuka’s Abilify (aripiprazole). Their positioning in the depression market targets the ‘add-on’ segment, improving control in patients with unresolved depressive symptoms.

This can be considered the rational or functional reason for choosing Abilify. But it is the emotional element of the positioning that really differentiates the brand: “Abilify teams up with the patient and their current medication giving the extra support and companionship required to put depression in its place, without having to start over.”

In a nutshell: teamwork, companionship, support. This is brought to life in their campaigns through the use of animation. The animation breaks out of the mental health category’s clutter of sad, ‘real’ people and instead features the patient in control of her disease, partly by objectifying it, and softens the topic of depression making it seem more manageable.

Abilify, then, is positioned to give the patient a sense of personal strength through companionship with the drug: “we will get through this together – you’re not alone”. Abilify is one of many examples of brands balancing the emotional and rational to gain the competitive edge.

As with all incremental improvements in competition, however, the arms race cannot continue to be fought forever using the same weapons, since increasing improvements in the balance between the emotional and rational will give ever-diminishing returns.

So how do we shake this up? Well, we at consultancy firm Strategic North believe it is time to redefine the battlefield for the next step in the arms race and start to think about the irrational and the unconscious.

The new marketing paradigm

Before we get into the detail, at this point we wanted to pre-empt some challenges we expect to this paradigm shift in marketing practice. Namely, that the pharma industry is evidence-based and evidence-lead, therefore clever marketing techniques might work when selling toilet roll, but selling medicinal products and influencing healthcare professionals is a different beast and different rules apply.

This is a good challenge, and we do not disagree that there is a distinct difference between the marketing challenges faced appealing to toilet roll customers and reaching prescribing customers. However, to be a little reductionist about this, both parties are making a choice, and the fact is that all choices are affected by heuristics and biases.

There is also strong academic evidence to suggest that prescribing decisions are influenced by marketing and sales, as well as the multi-million dollar research industry built on the back of campaign tracking – not to mention the countless brands like Abilify who feel the tug on the emotional has given them an edge. 

With that in mind, and thinking that pharma marketing is in the game of influencing choice and behaviour change, it makes sense to understand what influences choice, and shed some light on the power of the irrational and the unconscious.

The theory

A common buzz word in marketing at the moment is ‘Behavioural Economics’ (BE). BE is the study of economics through the lens of understanding that people do not make decisions rationally, and understanding how to apply that to improve economic outcomes.

It is the antithesis of neoclassical economics, which has all players making calculated and rational decisions in all walks of life. It is a clever merge between decades of social psychological research and core economic principles.

Relating this to pharma marketing is the same idea that pharma customers were once presumed to be – and sometimes still refer to themselves as – rational beings, and make calculated rational decisions. In BE, these individuals are called ‘Econs’ because of their objective and rational behaviour. The problem in economics is that Econs do not exist outside theoretical models; instead in the real world we are human beings who do not behave rationally and objectively.

Objectivity with choice is easy to understand when we consider the BE term of ‘choice architecture’. This is based on the simple premise that the way choices are presented will influence the choice-decision that is made.

In fact, the principle states that it is unavoidable for a choice not to be influenced by the presentation of options. Choice architecture is particularly influential when the choices to be made are complex and/or not made often, but it also works well in simple day-to-day decisions too.

It is easier to understand choice architecture with examples. So, you walk into your work café and out in front of you are a number of different buffet lunch options.

Are you more likely to choose the healthy salad option if it is the first bar you come to? If all the junk food is sitting next to the check-out, are you more likely to choose it? If you are holding a salad at the check-out, does that make the junk food option more or less likely?

In these scenarios, it is important to point out you have a choice to pick whatever you like; however, your choice is influenced by how the options are laid out to you – i.e., the choice architecture.

As an example of café-based choice-architecture in practice, at Google’s Manhattan office, they were so concerned about the health of their ‘Googlers’, that they recently moved their confectionery out of gravity bin dispensers and into opaque jars. What were the results? Googlers fat intake from confectionery decreased from 25% to 11 per cent. 

Again, importantly the option to choose was still there, but the ‘how’ of choice was altered. Therefore the role of the choice architect – the person who lays out the options – is important as they can influence and ‘nudge’ individuals towards a particular choice.

This nudge is the key tool in the choice architects’ armoury of weapons for behavioural change. Combining an understanding of choice architecture, nudges and some unconscious biases and heuristics can, we believe, have powerful implications for pharma marketing.

To make these concepts more tangible, we have selected two currently topical examples where understanding and considering these drivers could significantly improve outcomes:

•  Sales force effectiveness

•  Patient adherence.

Sales force effectiveness

As one of the authors used to be a sales representative, and we have worked with sales forces in many capacities, from research through improving effectiveness, we thought this would be an important area that could be improved by understanding unconscious motivations.

Sales representatives (and for clarity this phrase is used to include all customer-facing field staff) are in the game of influencing behaviour. Reps want physicians to come away from their discussions deciding “yes, this is a better product for x-patient, I will use it more often”.

But just how many sales forces are given training on behaviour change? In BE there are a number of well-researched unconscious biases humans have that can be used to aid persuasion. We will describe six of them here:

• Loss aversion: individuals are willing to work harder to avoid losing something than to gain it

•  Scarcity value: unavailability is more appealing than availability

•  Later is easier than now: individuals engage less with future events than they do with current events

•  Chunking: parts are considerably easier to deal with than wholes

•  Goal delusion: when multiple goals are pursued, they are less effectively achieved than goals pursued individually

•  Price perception: the price demanded for something is what individuals use to value it.

Touching on two of these examples, ‘goal dilution’ and ‘chunking’, one can see how reframing the sales communication in this light could increase effectiveness and nudge the customer towards a desired decision.

We have seen it countless times while sitting on both sides of the client-agency fence: the brand team have a number of areas they want the reps to focus on and so have drawn up six, eight, or even ten ‘key messages’ for reps to deliver within their calls.

Understanding the goal dilution principle, the more messages there are, the greater the dilution in the customer’s mind about the goals of that product. Therefore being clear and focussed on the target message will allow the customer to better position the product in their minds in terms of the goal it achieves.

Understanding chunking could also be an interesting persuasion principle used by sales representatives. Best practice benchmarking demonstrates that the most successful sales representatives break down the sales story into digestible chunks. They build the sales story gradually, convincing their customers of the brand virtues a little bit each time they meet.

This story evolution also means the representative has something new to discuss with their customers over time and can tailor their approach to their specific needs (still working within the set strategy), rather than just robotically repeating the same three messages each visit. Just think of the proverb – “Rome wasn’t built in a day”. 

Patient adherence

Many have described patient medication and healthcare adherence as the final ‘blockbuster’. Having done research in this area, however, most healthcare patient-adherence campaigns focus only on the premise that patients forget to take their medication or attend an appointment, and if that is solved then non-adherence can be solved. But it is estimated that forgetfulness only accounts for 30% of all non-adherence.

So the staggering fact is that 70% of non-adherence from patients is actually intentional. Intentional non-adherence is multifaceted and complicated and that is probably why most healthcare campaigns focus on the easier to understand 30 per cent.

There are a number of good examples of companies, health authorities and charities using ‘nudges’ to aid in improving patient adherence. Here we look at three of these nudges; incentives, defaults and ownership.

In Malawi, for example, incentives were used to change patient behaviour. Patients were offered an incentive worth around one-tenth of a day’s wage if they collected their HIV test results.

As a result, pick-up doubled. Clever use of the ‘default’ option is another case where changing the choice architecture can nudge individuals in the desired direction.

Physicians in Ohio have managed to successfully use defaults to nudge their patients toward regular cancer screenings by giving them a default appointment date and time. The patient must then opt out of the appointment by calling or be charged a fee.

In addition, by allowing patients to take ownership of their next appointment, attendance increases. In Bedfordshire, UK patients were asked to write their own appointment times down and repeat them back out loud to the receptionist staff.  

This small change dropped non-attendance by 30 per cent. As well as having a positive impact, choice architecture can nudge individuals away from adherence. Research at Harvard for example, found that patients were 50% less likely to refill their prescription if the colour of their epileptic medication varied (something common when using generics).

Understanding that patients must make choices and what influences those choices, can help shape choice architecture for the desired outcome.

Humans not in control

We hope that our whistle-stop tour of some of the basics around behavioural economics has shown how humans are not as in control of their choices as we might have thought.

In addition, we hope it has illustrated that biases and heuristics that affect our choices and behaviours can be influenced to change the outcomes. It is easy, at this point, for individuals in our industry to be uncomfortable about ‘influencing’ people’s behaviour. Our rebuttal to that conservative but pragmatic claim is simple:

•  Any choice made, would still be a choice. Individuals are free to choose another way

•  All choice is influenced. There is no such thing as neutral choice architecture, therefore why not nudge people toward better patient outcomes?

•  Pharma marketing involves promotion. Promotion is raising awareness and encouraging usage, both of which involve an element of persuasion and influence.

Therefore, considering the established evidence from psychology, economics and behavioural change, we believe, will lead to significant differentiation and competitive advantage, and can change our industry for the better, if used ethically, to drive better patient outcomes.

Harry Sharman is a consultant and Debbie Allman is a partner at Strategic North, a healthcare strategy consultancy