Here at Ethical Nag World Headquarters, I just figured out that it’s entirely possible I might have the concept of patient engagement all wrong. Until recently, I accepted this basic definition, courtesy of the Center for Advancing Health:(1)
“Patient engagement: actions individuals must take to obtain the greatest benefit from the health care services available to them.”
Sounds good, right? As a heart attack survivor with ongoing cardiac issues, I really liked the idea that a whole bunch of us seem keenly interested in doing whatever it takes to obtain the greatest benefit from our health care services. In fact, many folks far above my pay grade maintain that engaged patients may just represent the future game changers of health care. Health IT strategy consultant Leonard Kish, for example, wrote in August that if patient engagement were a drug, it would be “the blockbuster drug of the century – and malpractice not to use it.”
So I was pleasantly surprised when I was noodling around on Linked In one day and noticed that they have a few member groups discussing patient engagement there, too.
Hey! I consider myself an engaged patient – maybe I should drop in on one of these groups and see what other engaged patients are up to? Contemplating issues like doctor-patient communication, improved health outcomes and shared decision-making, likely.
It was only then that I found out: these groups don’t have patients in them.
What they do seem to have: corporate suits talking to other suits (and more importantly, to potential clients) about their companies’ role in taking financial advantage of this whole engaged patient movement. Consider some of the online statements from member companies in Linked In’s Patient Engagement groups:
- “(Our company) helps your hospital reach patients at the right time! By connecting your hospital directly with appointment-ready patients who are actively searching for a provider, you can reach patients right before they select a doctor or hospital.”
- “(Our company website) visitors are internet-enabled, commercially insured, profitable to hospitals and ready to take action once they’ve found information on our site:
- 73% have commercial insurance!
- 95% of those who make an appointment do so within a week!
- 38% of those who make an appointment do so on the same day!”
- “Designed to showcase your physicians and highlight clinical achievements, our solution connects you with patients who are looking for a health care provider within your community.
- Reach Patients at the Right Time!
- Increase Market Share in Your Local Community!
- Connect to Patients about Health Needs!
- Build Your Brand!”
Well, you get my drift. These companies are basically data mining, sniffing out those they hope might be most beneficial in supporting what’s really important here – their bottom line – by cashing in on engaged patients’ online search activities in order to drive new traffic through the doors of their companies’ provider-clients. Brilliant!
According to the U.K.-based Centre for Patient Leadership, the biggest asset health care has – the very people who live with health problems and use services – remains largely untapped.
“Instead, patients are a problem to be solved. Meanwhile, patient engagement has been co-opted by institutional interests as a buffer against change, rather than as a co-production engine for it.
“Despite the rhetoric of ‘nothing about me without me’, organisational approaches to involve people seldom move beyond tokenistic consultations, questionnaires, one-off projects or overly-bureaucratic structures with a seat for a lay representative. The engagement industry may gather data about patient views but seldom uses it to inform decisions.
“At the decision-making table, the role of the patient representative is not clear and there are too few training opportunities. Lazy organisations get a few representatives to cover a dozen different committees so they can tick the patient engagement box.”
Online patient discussion forums may not be the noble grassroots support groups that I once believed them to be, either.
Consider for example the site called Patients Like Me, a popular, for-profit, online patient community. Patients Like Me makes its money by selling health data gathered from its patient member profiles (with certain identifying information removed) to their “partners” (providers of drugs, devices, equipment, insurance, medical services) for scientific or marketing purposes.
The issue with this type of site, as described in The New York Times:
“While PatientsLikeMe is transparent about how they market patient data, patients have to be aware of the balance between sharing their experiences with other patients and being used for profit.
“Some people share their health information for the sake of the greater good. Yet they typically have no way of knowing whether their health profiles contribute directly to the development of more effective treatments — or are simply mined to create more effective drug marketing.”
In some unbranded “disease awareness” online communities, drug companies may pay people to moderate patient forums or pay celebrities to give testimonials, but might not prominently display that kind of financial relationship to patient/participants.
Other websites collect consumer health data to help companies target marketing to specific kinds of consumers.
And because many patient forums don’t have unbiased physician moderation, they may also be vulnerable to influence from corporate partners, drug company marketers, or those pushing unproven therapies. We’re already seeing this in industry-sponsored sites including:
- TheDx diabetes site from drug giant Sanofi-Aventis has over 7,000 Facebook fans and 7,000 Twitter follower
- diabetes juggernaut Novo Nordisk sponsors IndyCar driver Charlie Kimball in exchange for his Tweets – @racewithinsulin – including whenever he injects with their products
- Johnson & Johnson financed The Fatigue Coalition – a patient-advocacy group that promotes off-label (unapproved) uses of the J&J drug Procrit to treat fatigue in cancer patients, despite studies(2) concluding: “These agents are effective in the management of cancer-related fatigue but also raise serious concerns about safety data and adverse outcomes associated with these agents. The review concludes that these agents SHOULD NOT BE USED for the treatment of fatigue in patients with cancer.”
- Mark R. Westlock, a former Pfizer drug rep from 1991-2007, revealed (in the ultimately successful whistleblower lawsuit that resulted in record-breaking $3.2 billion criminal fines) that the world’s biggest drug company had funded the advocacy group, National Alliance on Mental Health, “in order to turn the non-profit into a ‘Trojan Horse’ that would promote the antipsychotic drug Geodon for non-approved use in children.” The number of antipsychotic drug prescriptions written for children doubled to 4.4 million between 2003 and 2006.(3)
- The new startup site MyHeartDiseaseTeam (inaccurately described on its site as“…the only social network where you can truly connect, make real friendships, and share daily ups and downs in a judgment-free place” which is of course untrue – there are many such online sites). The site does warn potential members: “On occasion, we will partner with a pharmaceutical company if we believe it will benefit our members”, begging the question for heart patients: how do their financial relationships with Big Pharma or other industry partners benefit anybody but themselves?
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UPDATE February 10, 2016: Journalism watchdogs at Health News Review report that the pharmaceutical industry is now turning to an old tried-and-true ploy: the fake or “Astroturf” patient-advocacy group in order “to improve its reputation with lawmakers as it lobbies against any effort to rein in prescription costs.” The report specifically looked at one such group, Patients Rising, along with its partner organization Patients Rising Now, co-founded by a California PR guy named Jonathan Wilcox. But Patients Rising’s website provides no indication of who is paying for the group’s considerable activities, as HNR reporter Trudy Lieberman explained:
“Astroturfers gather ordinary citizens from the grassroots to advocate for various causes while in reality shilling for the trade associations, PR firms, corporations, and political organizations that set them up.
“Like most Astroturf groups, its purpose [‘to fight for access to vital therapies and services for patients with life-threatening diseases] seems noble enough and its goals lofty. But in reality, the group’s main goal is to push against the developing meme of unaffordable drugs. And, like other Astroturf groups (such as Even the Score, which in 2015 successfully persuaded federal regulators that not approving the drug flibanserin for the treatment of ‘female hypoactive sexual desire disorder‘ somehow represented gender inequity), Patients Rising does this under the guise of being a grassroots patient organization.”
♦ ♦ ♦
Trouble is, the FDA has not yet written the rule about how pharmaceutical companies specifically are allowed to engage with potential customers and patients through these types of industry-sponsored sites and organizations.
In the same New York Times article mentioned above, Jeff Chester, director of the Center for Digital Democracy (a nonprofit group that works to safeguard user privacy) had this warning about online patient engagement communities:
“We are talking about a digital pharma stealth economy that is emerging.
“You don’t know who is being paid to moderate. You don’t know who’s listening in to your conversation. You don’t know what exactly they are focused on and what they are doing with the information.”
Dr. Catherine Dwyer is an associate professor at Pace University who has studied how advertisers market to consumers based on their online behavior. She told the New York Times:
“I’ve been really, really shocked at the blatant manipulative language that some sites use to describe their corporate services to industry – versus how they describe themselves to consumers.”
Drug companies have a lot to gain by the trend towards patient engagement, but not for the reasons you might think. A major headache for Big Pharma is the patient who won’t take the drugs that doctors have prescribed. This reality represents a significant financial loss for pharmaceutical companies that have spent millions to get those initial prescriptions into the bathroom medicine cabinets of the world.
For example, about 50% of patients with chronic conditions stop taking their prescribed medications, and one-third of all prescriptions are never filled in the first place. This lost sales opportunity costs the pharmaceutical industry an estimated $30 billion per year.
That often-used number might in fact be a gross underestimation. A new report has found that the U.S. revenue loss is a whopping $188 billion – and extrapolated to the global market, that’s $564 billion in lost revenues worldwide.
So the drug industry worries about how to improve “compliance” (a word that so many of us patients hate) or the slightly less patronizing “adherence”. No wonder drug companies have started launching patient engagement programs to address non-compliance.
And as one 2008 industry trade paper warned:(4)
“Any drug compliance program implemented must be able to provide improved compliance with the brand, as well as improved bottom-line profit for the brand.”
This same paper advised on just how drug companies can combat this non-compliance. For example, patient compliance program approaches that have been successfully tried (each of which sounds like patient engagement strategy) are:
- patient education
- cost-related approaches
- direct-to-consumer advertising
- delivery options and dosing regimens
- call-center support
- Short Messaging Services (SMS)
Speaking of drug companies, when Charlotte McKines, a woman with the impressive title of Global Vice President of Marketing Communications and Channel Strategies at Merck, delivered her presentation called “How Digital is Transforming the Pharmaceutical Marketing Model” at an ePharma Summit in New York City last February, she warned her colleagues:
“About 86% of our customers use the web to gather information, but more importantly they use the non-pharmaceutical sites to get information about our products. They really don’t have a lot of trust and value right now in pharmaceutical sites.
“So we really struggle in life sciences to become a primary trusted source. We have got to get there because finding the right place and being in the right destination for our customers really does give us the competitive advantage.”
Well, cheer up Big Pharma!
If you can’t get your customers to place “a lot of trust and value” in your own sites, you can always co-opt patient engagement resources to get your marketing messages out there – without us even knowing that you are the messenger.
For example, the website called Script Your Future appears at first blush to be a useful campaign targeted at patients designed simply to “help you take back your future by helping you take your medicine as directed.” But what visitors who sign the site’s I Will Take My Meds pledge may not know upfront is that the campaign’s funders include drug companies Boehringer Ingelheim Pharmaceuticals, Inc., Astra Zeneca, Eli Lilly, GlaxoSmithKline, Merck, Pfizer, Proctor & Gamble and Sanofi-Aventis. And by signing the pledge (and ticking off the too-small-to-read “I have read. . .” box), you’ve just identified yourself as a patient and handed over your personal contact information to Big Pharma for future marketing campaigns.
Remember that marketing practice I mentioned earlier called astroturfing? It’s perhaps best exemplified by a company called Lifestyle Lift that ordered its employees in 32 centres to post fake positive reviews online about its $5,000 quickie facelift procedure. Everything was going along just fine with the fake review strategy until New York Attorney General Andrew Cuomo got wind of it and launched an investigation into the practice, resulting in a $300,000 fine. (See also: Sock Puppetry, Astroturfing, and the Marketing ‘Shill’ Game)
At the risk of seeming cynical – ooops, too late! – I have to wonder, sadly, if there are any last bastions of genuine safety and trust out there for patients who sincerely want to be actively involved in untainted patient engagement.
(1) Center for Advancing Health. 2010. White paper: “A New Definition of Patient Engagement: What is Engagement and Why is it Important?”
(2) Minton O, Richardson A, Sharpe M, et al: Drug therapy for the management of cancer-related fatigue. Cochrane Database Syst Rev 7: CD006704, 2010.
(3) Jim Edwards, “Pfizer Turned NAMI Into “Trojan Horse” to Push Geodon Off-Label to Kids, Suit Claims,” BNET, 16 Sept. 2009.
(4) Dr. Andree K. Bates. DTC Perspectives. March 2008. “Patient Compliance Programs: How to Ensure They Are Not Doomed to Fail”
- This article was simultaneously published on Reporting On Health today.
What Really Goes On in Your Friendly Online Patient Group
“I’m Not a Real Doctor – But I Play One on Drug Ads”
How Big Pharma Spends $20 Billion a Year on Marketing Their Drugs to You
“Sleazy Example” of Drug Company’s Reminder Ads on Twitter
Paying Celebrities to Shill your Drugs
Why Big Pharma Wants Your E-mail Address
Sock Puppetry, Astroturfing, and the Marketing ‘Shill’ Game
When the Elephant in the Room Has No Smartphone – from my other site Heart Sisters (more on Medicine X, self-tracking, skinny jeans and “stark raving narcissism“)
Well put together. In the MS World we are particularly a target for all providers since we are a cash rich disease.
Thanks for this perspective, Laura. It’s sad that patients even have to think of their diagnoses as a “cash rich disease”, isn’t it?
It is generally the old “who pays the piper?” issue. Patient groups which rely on pharma (or other industry player) for most of their funding will end up being influenced by the funder. The worst case of this has been with promotion of oxycontin by “pain groups” which had pharma backing.
And yes, compliance programs are about boosting sales.
Transparency is the key.
Good points, Dr. Joe. That’s why it’s incumbent on patients ourselves to read the fine print, look for the company logo, follow the money.
Having made an unexpected visit to a local hospital about a year ago, I was shocked to find that “hospitalists” is a new group of medical doctors who only see patients in the hospital – they do not have a private practice, are not required to notify your family or personal physician, do not have to call in a specialist if you request one, even when your symptoms require one….what a shock.
Later, at the office of my specialist, I overheard another patient conversation while in the waiting room – he was telling the person he has just been released from ___ hospital and Dr. ___ had nearly killed him. That was the same doctor that I was subjected to, and thought perhaps he just didn’t like women or was having a bad night/day.
It is a new practice for hospitals to use these practitioners where once the hospital called your personal physician. Most of the private practice physicians do not go to the hospital any longer – or so I am told.
Hello Ray’s Mom – Hospitalists are indeed an emerging career path for MDs but I’m pretty sure they cannot practice without “notifying your family or personal physician” or “calling in specialists”. Learn more about their actual role here. As for overhearing that waiting room gossip, I’d take that 3rd hand “nearly killed him” opinion with a grain of salt – using the same critical ear we should be using when evaluating the marketing messages of Big Business.
I had read about infiltration on ‘health-rating websites’ by providers who skewed their patient driven results to appear more positive than they actually were, but this is a whole new level of awareness! Carolyn, you are a gift to those of us who want to be helpful using our credentials in a positive way (I’m an NP) although retired with brain fully engaged!
We keep being told that cyberspace is a dangerous world; you have just proven once again, the need for caution and awareness.
Thanks Lynn – the interesting part of this is that business does not view this practice as “infiltration”. It’s simply good marketing strategy to reach your target market.
Hi Carolyn your perspectives are shared by many. I’ve been in healthcare for over 25 years and find it awkward to attend meetings with so many highly educated and accomplished healthcare professionals who talk effusively about new higher standards of care that include the patient i.e., Patient-Centered Care, Patient Engagement, Patient Activation, and Patient Empowerment as though these were routine behaviors integrated across their organizations culture when they’re simply not.
Several talk the talk but few invest in transforming these words into matching actions that make a difference. Whether it’s political will, a matter of resources or a combination, it’s easy to make the distinction by comparing those organizations content with “statistical sample sizes” and those striving for perfection to learn the perspective of “every patient encounter”, making this a concrete measure by which they benchmark themselves internally and externally.
Perfection is really important when you’re entrusted the responsibilty for people’s lives; statistical sampling is simply inadequate for the precision required to ensure “consistent” high quality care. Examining the outcomes of every 100 or so patients rather than emphasizing the importance of each individual encounter contradicts the principles of Total Quality Performance (perfection) which we assume consistent high quality care means, but again is often just another co-opted term.
People (patients) deserve better. Until they are routinely empowered with a voice (Patient-Centered Care, Patient Engagement, Patient Activation, and Patient Empowerment) the opinion that they are getting what they need, prefer, and or are paying for, when they need it, will always be one-sided.
The company I’m involved with, “CarePartners Plus”, the makers of “Wellby”, concentrate on providing practical tools for patients (people) and providers to use to foster new behaviors that help improve outcomes in the office and beyond and in the process help the health care system improve as well.
We specialize in making it feasible to empower, engage, and activate the patient.
Thank you for the opportunity to express my observations about co-opting Patient Engagement. I will continue to follow your columns.
Hi Mike and thanks for sharing your perspective here. It seems to me that there are two basic kinds of “engaged” patients out there: the first group consists of those who (like me) have always been “engaged” and then one day become patients (my old Public Relations friends tease me that this is just what happens when a PR person has a heart attack – they just keep on doing what they know how to do: write and speak!) This group is sometimes vulnerable, however, to for-profit interests who (think Paula Deen’s lucrative endorsement deal with her diabetes drugmaker Novo Nordisk) identify public partnerships with engaged patients as good for business.
The second group contains the patient who may have never felt particularly empowered/interested in things like developing personal health goals (“That’s what my doctors are for!”) but can evolve into engagement precisely because of the way the health care team begins to change the practice of medicine. That’s how I understand the roles of companies like yours that essentially require physician buy-in first by offering some clear financial advantages to the practice (like that quality-outcome documentation that insurance companies are requiring) as well as inherent health benefits to the individual patient.
In both cases, I’d like to see some bona fide numbers based on evidence to avoid the co-opting of patient engagement as the Next Big Thing in health care.
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Thanks for shining a light on this.
I observe the situation from the standpoint of a researcher who is often asked to be the “patient voice” at conferences. I am happy to provide data and insights based on survey research and fieldwork, but I also try to educate conference organizers about how to *really* include the consumer point of view. I wrote a post about how I do that and it’s generating an interesting conversation. I’d love to have you and your readers join in, if you have time:
One objection I’ve heard to including “real people” in professional meetings — whether pharma or medical or other industry — is that it is sometimes not appropriate to include emotion or N=1 storytelling and experiences. I’m not saying I agree, I’m saying that is what I’ve heard.
In those cases I think of — yes — PatientsLikeMe and their emphasis on tracking real people’s experiences with medications and treatments. The company is transparent about their mission and tactics and they use the data they collect to write scientific papers and to win a seat at the table with pharma, clinicians, scientists, etc. I’ve heard various forms of the following quote, attributed to Sir Austin Bradford Hill, pioneer of the randomized clinical trial, and would like to hear what you think of it: “Health statistics represent people with the tears wiped off.”
Other patient- or family-led condition groups who I have heard have wielded power at scientific meetings: cystic fibrosis, Parkinson’s, breast cancer…
So maybe we can begin to talk about a taxonomy of patient engagement. And a taxonomy of organizations who attempt it, with various levels of success or cynicism.
Hello Susannah – lovely to hear from you, as always. I did catch your current post and have been meaning to respond! Stay tuned… As mentioned above, PatientsLikeMe is transparent about selling their data (transparency is good!) but as the NYT confirmed, patients “typically have no way of knowing whether their health profiles contribute directly to the development of more effective treatments — or are simply mined to create more effective drug marketing”. THAT’S my concern.
And those “real people” organizing professional conferences who are not interested in having real patient voices included will always come up with a rationale to explain the exclusion (like the doc who left an online comment recently saying that he gets to hear the “patient perspective” all day long in practice, so why should he have to sit and listen to more patient stories at his conferences? I’ll be sure to leave a comment on your post, and I encourage my readers here to do so as well. Many thanks…
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