4
Chapter Outline
| 1. | Introduction |
| 2. | Understanding Consumer Behavior |
| 3. | Conducting Market Research |
| 4. | Creating the Marketing Plan |
| 5. | Chapter Summary |
| 6. | References |
| 7. | Web Resources |
 | Web Toolkit available at www.ashp.org/ambulatorypractice |
Chapter Objectives
1. Identify the phases a consumer goes through during the decision-making process.
2. Recognize service characteristics that increase marketing difficulty and identify strategies to overcome the barriers.
3. Compare and contrast different methods for conducting market research.
4. Plan and execute an appropriate marketing strategy.
Introduction
An ambulatory care pharmacy practice, like any other type of business, requires marketing in order to be successful. Without it, a patient may not be aware that your service exists, a health care provider may not refer patients to you, an administrator may not include you in organizational plans, or a payer might not consider providing reimbursement for your services. Each of these scenarios decreases the likelihood of continued viability for your ambulatory care practice model.
Marketing is commonly mistaken as simply promoting an existing product or service, but according to the American Marketing Association, marketing is the “…processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large.”1 A definition that may resonate more with you as a clinician is provided by Hillestad and Berkowitz in their book on health care marketing: “Marketing is the process of understanding your customers’ wants and needs, listening to those wants and needs and then, to whatever extent possible, designing appropriate programs and services to meet those wants and needs in a timely, cost-effective, competitive fashion. It is the process of molding your services to the market, rather than convincing the market your services are what they need.”2 There are several key concepts in both of these definitions. First is the word, value. You, as an ambulatory care pharmacist, may feel that the service you provide, no matter what its setting, has the ability to help patients achieve better health outcomes, but this does not necessarily equate to value for others. It is the buyers who need to feel your service is beneficial so they will exchange their offering of value: money. Second, you may have been trained in your residency to provide a diabetes-related service, but in the patient population you are planning to service, diabetes may be well controlled due to other providers or payer incentives already in place. Although it may be ideal and easier to create a service in which you are experienced, this may not be the need in the clinic in which you are proposing your service. If you do not understand your customers’ needs, your attempts to add another cog into a currently well-oiled wheel may not work. Rather, you need to use those same skills to build a service that will meet something your customers are not currently doing well.
 | Marketing requires an understanding of the wants and needs of the consumers of your service and a plan or marketing strategy that successfully promotes and delivers your service at an acceptable cost, ultimately resulting in a satisfied customer. |
Unlike other industries where there are one or, at most, two types of customers, an ambulatory care pharmacist is unique in that there are three to four target groups. Of course, as an ambulatory care pharmacist your primary customers are your patients, as they are the direct recipient of your services. Other health care providers, primarily physicians, who refer patients and with whom you will collaborate, are indirect consumers in that your services support their work and responsibilities in patient care. The patient usually does not pay for your service; therefore, payers or insurers are third-party customers with significant influence on how you will be reimbursed for your services. Most ambulatory care pharmacists will practice in larger organizations or a newer health care model, such as accountable care organizations, which add administrators as a fourth consumer. Administrators have the responsibility to keep the organization viable while providing quality health care services. They need to understand and determine which providers are best suited, considering licensing, knowledge, efficiency, and cost, to execute the business of patient care services within your organization. Administrators are customers in that you need to demonstrate that your pharmacy services fit as the best provider for a set of services provided or to be provided by the organization.
 | When marketing clinical services and understanding your customer or consumer behaviors, you need to consider and target all potential target groups. |
Successful marketing for your ambulatory care clinic requires three steps. The first step is the basic understanding of your customers’ behavior and the connection to the inherent characteristics associated with your services. It is essential to understand why and when a person makes a decision to fulfill an unmet need or want so that you know what information a person needs and when that person needs it in order to determine if your service offers something of value. It is also crucial to be aware of service characteristics that make it difficult for a buyer to determine value. In particular, there are several barriers to overcome when getting target groups to value a newer health care service such as pharmacist-provided services in an ambulatory clinic. After the first step of background knowledge is complete, the second step is conducting market research to understand target groups’ wants and needs, as well to identify your potential competitors, and then determining how you can better meet the wants and needs of potential partners. Armed with all of this information, the third step is crafting the message that will convey your value to all groups and determining how you can most efficiently relay and deliver that message. This chapter provides the background information necessary to successfully complete each of these steps and provides useful tips and examples for how to incorporate the presented concepts into marketing your ambulatory care pharmacy model.
Understanding Consumer Behavior
Consumer behavior is the psychological processes individuals go through in recognizing needs and finding products or services that will meet those specific needs.3 Of the numerous models proposed by marketers over the years, seemingly the most popular divides the consumer decision-making process into three stages.4 In the pre-purchase phase, a consumer recognizes a need and searches for ways to meet that particular need. During consumption, the consumer chooses and procures a product or service. After this has occurred, a consumer will evaluate his or her experience. The reality of the post-purchase experience is compared to the expectations held prior to consumption.
Pre-purchase Phase
A model for buyer behavior is every stimulus engenders a response. This is where the consumer’s decision-making journey begins: a stimulus that brings awareness to an individual’s need. For a patient, especially with a chronic disease such as heart failure, this can be as simple as experiencing shortness of breath or leg swelling and desiring relief from those symptoms. For a diabetic patient, the stimulus could be the results of physician-ordered lab work, HgA1c levels, and the recognition that something must change if the patient wants to maintain or improve his or her current level of health. A physician may recognize that a large number of patients in the practice are not at therapeutic goals and need more intense education and monitoring regarding medications or diseases, and the physician does not have time to provide it. An administrator may note decreased pay for performance revenue due to the organization not achieving benchmarks for patient or disease state outcomes and thus is looking for effective cost-efficient changes in the processes to improve performance measures. A payer may note a certain population, such as heart failure patients, exceeding average yearly costs due to a high rate of rehospitalizations and be in search of a program that will effectively help control these costs. Each of these consumers may not have considered or sought out pharmacist-provided ambulatory patient care services, but each may find, if informed, that these services address his or her current health stimuli. As you think of marketing, how do you as an individual practitioner ensure that you are considered a potential solution to each of these customers’ needs?
CASE
Dr. Busybee realized he was going to lose one of his biggest payers if he did not find a way to decrease patients’ HgbA1c levels as well as increase the percentage of time their INRs were in target range. His administrators prompted him to research what would be needed to meet the payer’s treatment goals. This research led him to conclude that the clinical pharmacy services you plan to provide will help him with his patient care goals. You both meet with the office administrative team to present your business plan and get the approval for you to join the practice. Administration personnel are unclear about the value you bring to their operations, as they have never witnessed this type of pharmacy practice and are concerned about the potential cost of the program. After reviewing your business plan, however, they are enlightened regarding the possibilities of this service and would like to see it, not just for Dr. Busybee’s patients, but expanded to his partners’ patients in the practice setting. They have noted that this physician group is performing below other local physician groups on health outcomes for several of their payers, and this is negatively affecting revenue. Using your services is an attractive option, and they request that you work with Dr. Busybee to determine the best plan for your integration and collaboration with all the physicians of the practice. They inform you they are in negotiations to secure preferred provider status with an additional payer. They ask you to identify how your services may benefit them in these negotiations.
Consumer Stimuli
To better understand the external forces involved, consumer stimuli are usually divided into three categories: commercial, social, and physical.
Commercial Stimuli
Television, radio, and Internet advertisements constantly bombard consumers about products and services, including those associated with health care. Are we sleeping enough? Do we feel tired all of the time? Are we anxious? Are we sore? Do we need life to just slow down a little? In our medical world, we witness constantly the marketing of new medications, services, and equipment from salespeople in our institutions, offices, and meetings. These types of advertisements are considered commercial stimuli. (Sample MTMS Brochure and MTMS Patient Brochure)
CASE
Knowing that expansion of your practice to include collaboration with all physicians of the group will take time, you initiate the marketing process by targeting Dr. Busybee and his patients. Your first step is to read a book entitled Building a Successful Ambulatory Care Practice: A Complete Guide for Pharmacists, then you start brainstorming not only how to create a marketing plan for your current practice implementation but also for expansion of your practice over the next 1 to 5 years. The use of commercial stimuli is one strategy suggested to reach the physicians and their patients. You would like to model the pharmaceutical sales approach and use written material such as a brochure with an appealing message and title. You think about some catchy lines, such as “Can’t seem to get that patient’s HgA1c levels below 7?” or “Warfarin management putting you over the edge?”, and plan to follow them with information on your service and patient referral. You are also thinking of planning an in-service at a physicians’ meeting, as well as placing the brochure electronically as a link on the organization’s intranet web site. You are also considering developing an easy-to-use flyer placed visibly in all physicians’ exam rooms and nursing stations to remind them to refer patients appropriate for your service and guide them through the process.
You anticipate that when Dr. Busybee’s patients are referred to you they will have a poor understanding of why they should see you and what you can offer them. Realizing you need a plan for this target group, to explain your service you develop a brochure with another catchy title, “Why Does My Physician Want Me to See a Pharmacist?”, written in terms and phrases easily understood by patients. In that brochure, you address the services you will provide and explain how they will help patients manage their disease states.
Additionally, you will need to address the administrators’ request to identify how your services can benefit the payer negotiations. This task has you overwhelmed, and at this point you are not quite sure what that plan should entail.
Social Stimuli
Social stimuli can also initiate the consumer decision-making process. This can occur when a friend or colleague recommends a product or service, or in some instances, the stimulus is an individual’s desire to be more like someone he or she admires or envies. Social stimuli can be particularly important for clinical service providers because an individual experience with the first clinical ambulatory pharmacist they encounter will shape his or her perceived value of that service. This is particularly true for patients and their providers. A satisfied patient or physician may provide a positive word-of-mouth referral to a friend, thus initiating a social stimulus and awareness of need. Since health care decisions often involve a weighing of both emotional and practical factors, this reference may serve as the deciding factor about whether or not your primary customers will use your service.
Do not discount this method for administrators and payers. As medication therapy management continues to evolve into health care legislation and payer initiatives, and experiences with pharmacist ambulatory services reach these groups through publications and meetings, they may have already heard about such services. The presentation of your business plan with your services may align well with their social stimuli and be the impetus to gain support or achieve final approval for your services. Coming armed with support for ambulatory pharmacist-type services from material found in each customer’s social or professional base can be one way to optimally use this concept. Have the publications or organizations for your administrator’s peers addressed your type of services?
CASE
Knowing that Dr. Busybee understands your proposed services well and is well liked and respected by his peers, you ask and he agrees to be part of your campaign to inform his partners of your new services. He agrees to share the impact you are having on his patients’ care with his partners to stimulate referrals to your service.
Physical Stimuli
The final way that consumers become aware of needs is by experiencing physical stimuli. If a patient experiences an adverse reaction to a new medication, he or she will seek ways to alleviate the pain and discomfort of that situation. Someone who is experiencing bleeding with their anticoagulant will call the physician’s office. A need you can fulfill is to lighten the load of your triage nurse by accepting those calls in your service. The example of an unexpectedly disconcerting lab or test result could also be classified as a physical stimulus. A patient may have a HgA1c greater than 10 or new atrial fibrillation on EKG at a physician’s visit; this stimuli can be used for an automatic referral to your services. If your payer or organization has financial attribution for rehospitalization for certain conditions, those patients may be automatically referred to you for a visit upon discharge as an effort to control those costs.
CASE
Physical stimuli could really help jump start your referrals. With the support of administration and Dr. Busybee, a report is generated identifying all of his patients with HgA1c levels greater than 10, as well as those patients with poor time in therapeutic range for their INRs. Dr. Busybee’s partners are informed that these are the types of patients he is referring to your service. They will be provided with the names of their patients that fall into these categories as potential patients they may refer to pharmacist services.
How to Address the Need
After a consumer becomes aware of his or her need, the next step in the pre-purchase phase involves a search for ways to address that need. This search can occur either internally or externally, but often one leads to another.
CASE
In Chapter 2 Dr. Busybee was a potential customer for your service. However, before he contacted you he may have investigated resources currently within his practice to address the large number of patients with HgA1c levels greater than 10 and those with INR out of the target range. His office may have another practitioner such as a certified diabetic educator or a nurse practitioner that could help him manage these poorly controlled patient populations. For example, he may recall that one of his nurses had worked previously in an endocrinologist office and may have some base knowledge in diabetic management to provide additional education needed by his patients.
This would be classified as an internal search. If the experience with the nurse practitioner or diabetic educator is positive and patients’ HgA1c and INR levels are improving, there is a strong likelihood that Dr. Busybee’s search for alternatives will end here. However, if Dr. Busybee is facing a need that has not been previously realized or experienced, or if past methods to fulfill this need have proved unsuccessful, such as having no personnel in his office who could take on these populations, then an external search for alternatives becomes necessary.
During the external search process, Dr. Busybee seeks information from outside sources. These sources might still include recommendations from colleagues, professional journal articles, advice from administration, or even a search of the Internet. At this point, the information gathered is unprocessed by Dr Busybee, who is the customer. The level of effort put forth in this search will vary and will be affected by numerous factors, including an individual’s attention span, perceived seriousness of the need, or the amount of information available to the searcher. Sometimes an overabundance of available information can be overwhelming to a customer and can be just as detrimental as a lack of information.
At some point, the customer will reach his or her own threshold for information gathering; then the evaluation process begins. All potential methods for fulfilling the customer’s need that were identified during the internal and external searches will now be compared and contrasted with one another. Weighing the pros and cons of each alternative can be a fairly analytical process; it is not uncommon for emotional factors to influence these decisions as well. The price of a service may be an important element for Dr. Busybee to consider, but a clinician’s availability and reputation for service and results may elevate Dr. Busybee’s estimated value of this service. In our case, Dr. Busybee’s external search found you! He may have considered other options, such as a higher level and more expensive service provided by hiring a part-time endocrinologist. He could consider hiring a nurse or a diabetic educator. If the cost of services is comparable to yours, but one is less available or lacking an equally positive endorsement from colleagues, then the customer, Dr. Busybee, can decide what is his best choice. How well you positioned yourself and promoted yourself to meet Dr. Busybee’s needs are key in his choice.
Consumption Phase
After identifying and considering the various ways to fulfill their need, customers ultimately make a choice about what services to consume. When they do, they enter the consumption phase of the customer decision-making process. This involves not only the consumption of the product or service itself, but also the way it is utilized. From a clinical services standpoint, this phase would include the patient and his or her choice to visit your practice site and the degree to which he or she utilized the services offered. For the physician or other health care provider it will be how beneficial they find your service and their resulting willingness to continue or increase your patient referrals. Administrators and payers will be evaluating the value of your services from their perspective or how well you meet their quality and cost measures as noted in Chapter 7.
Post-purchase Evaluation
The final stage of the consumer decision-making process is the post-purchase evaluation phase. How does the reality of the purchase compare with the consumer’s expectations? Did the purchase adequately fulfill the consumer’s needs? Did the experience disappoint or exceed expectations?
With the benefit of hindsight, a consumer can now evaluate his or her own decision-making process. Were the trade-offs of another patient visit, choice of you as a clinical pharmacist versus another provider, and cost of your service justified by the level of services rendered and patient health care outcomes you impacted? How heavily did emotional or political versus practical factors weigh on this decision? Was it the correct decision?
If cost was a concern during the decision-making process, it is not uncommon for consumers to begin to doubt their own choices. To override such concerns for your pharmacy service, your value proposition has to be well balanced between cost, worth, and quality of your service to patients and referring providers and the resulting patient health outcomes.
The following are some tips for incorporating the consumer behavior principles into your marketing activities.
1. Consumers routinely seek out information to satisfy needs, so be a visible source to all your potential customers. Make sure each customer has heard about ambulatory pharmacy services, including patients, physicians, administrators, and payers.
2. One-to-one interactions with your target consumers to inform them of how you can meet their needs with your services is always an effective strategy. Be persistent in securing the face-to-face time, which allows the potential customers to associate the service with a person and that person’s vision.
3. Have pertinent written information readily available for all types of customers. The information should address their needs and how your services can and will meet them. Think about your business plan from Chapters 2 and 3.
Characteristics of Services
Product versus service is the defining comparison for what you do as a clinical pharmacist compared with those who sell a physical product. Promoting a service creates a significant challenge for marketers.
 | Unlike tangible objects that can be seen, touched, felt, weighed, or measured at any time to determine their usefulness and value, services are moments-in-time experiences, and their unique characteristics make assigning value a bit of a challenge.5 |
As already noted, the first characteristic of a service is its intangibility. It doesn’t exist before it is delivered.5 In a clinical setting, you bring your specialized knowledge to interactions with patients and other health care providers. As a pharmacist, you educate, provide advice, and monitor. For each encounter, whether with a patient or provider, your service is unique and provided in the moment. The personal nature of these experiences makes them difficult to explain and understand, especially when you are marketing your services to someone who has never experienced what a pharmacist can do in terms of direct patient care. Consider someone telling a friend about the new sports car he or she just purchased; “it’s red with racing stripes, dual exhaust, leather sporty seats with a great stereo.” It is easy to visualize the car being described in exact detail. Now think about the same person telling a friend about the medication evaluation session a pharmacist just conducted for him or her; “well, the pharmacist looked at the computer, asked me some questions, wrote something down, spoke with my doctor, and then I ended up with a different medicine, directions, and things I am supposed to do.” The acquaintance has a very difficult time visualizing what their friend just “bought” at the visit with the ambulatory care pharmacist. However, there are visual clues that indicate what type of services may be offered or expected. The professional nature of your brochures, how well and professionally you communicate, the professional appearance of both you as a provider and your practice setting all leave visual impressions. These visuals paint a picture that can be relayed. People conveying their experience can add that the pharmacist was very attentive to their needs and really helped them manage their condition by answering all questions in a manner laypersons can understand. Other visuals, such as a busy or noisy office with minimal privacy, do not readily convey that personal or comprehensive clinical services will be provided. A practice site that provides a comfortable, professional waiting area with private consultation or exam rooms indicates that professional services are being provided.
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