Spotlight

The Internet: Changing the Managed Pharmaceutical Care Environment

Susan Fox

Consumer prescription drug behavior is changing. Consumers are more demanding, with higher expectations for service, information, and alternative solutions to their health care needs. Several factors are driving these changes, including aging patient demographics, direct-to-consumer prescription drug advertising, and rising drug costs. Concurrently, declining margins and increased competition within key segments of the health care delivery system are affecting both benefit designs and consumer marketing programs.

The increasing use of technology-specifically the Internet-is also directly and indirectly shaping the health care landscape and the prescription drug consumer's expectations and behaviors.

Pharmacists are encountering consumers armed with reams of information from the Internet about health care in general, specific diseases, prescription and over-the-counter drugs, and alternative or experimental therapies. Managed care plans may face groundswells of con-sumer activism demanding changes in benefits and policies to allow coverage of specific drugs, expanded consumer choice, and access to medications that are not yet approved in this country. Consumers increasingly use online opportunities to transact business traditionally conducted by mail, phone, or in person-including buying prescription medications and consulting with medical professionals.

HEALTH INFORMATION ON THE INTERNET

The 70 million adults in the United States who use the Internet, while still younger and more highly educated than the population at large, are more representative of the general population than the earliest pioneers of the Internet, who were predominantly male, young, and technically skilled.

Of the adult Americans who use the Internet, 36% report going online at least monthly to meet a health care need for information, advice, community interaction, and to obtain products; some two-thirds report that they have used the Internet to search for health information on some occasion. The people who use health care Internet applications-dubbed HealthMed Retrievers by the New York-based market research firm Kalorama-are generally better educated, more affluent, disproportionately female, and far more likely to spend money online than the average Internet user. In short, they are distinctive and highly attractive consumers.

This level of interest in Internet health care information has prompted many organizations to establish health care Internet sites, expand their sites to include a health care component, or plan such sites for the near future. Online consumers have myriad options to re-search health information, network online in virtual communities, communicate with medical professionals, buy health care products, and locate providers.

ELECTRONIC ACTIVISM

Virtual communities, which exist through electronic chat rooms and bulletin boards, allow users to ask questions, share experiences, and view and respond to messages from others. Virtual communities often are built around special interests, such as specific health care concerns. Activism sparked and enabled by the Internet can be powerful; it already has influenced the care of patients with cancer, AIDS, and depression.

Electronic forums may be completely open, be moderated, or offer scheduled opportunities for participants to talk with an expert. Open chat rooms, which are very popular, are exactly that-open. Messages that users submit are broadcast virtually instantaneously, without consideration of the quality of their content. Historic messages are retained and are available for review. Chat rooms offer participants a forum that is even more free than barbershop conversation.

Moderated forums, such as those hosted by Mediconsult.com, give users similar opportunities to view messages posted by others in the community but with one key difference: In moderated forums, messages from users are subject to review before broadcast. The Web site host sets the standards for which messages may be broadcast. Those standards vary based on the host's interests and objectives. Mod-erators may suppress messages completely or add qualifying messages.

Virtual communities also may provide opportunities for users to enter into a public electronic dialogue with a specific individual-typically a subject-matter expert-or to observe the expert's dialogue with other participants. These forums generally are scheduled and promoted to attract people. Internet sites also may give users opportunities to have private exchanges with professionals. In recognition of consumer demand for ready and confidential access to medical professionals, many sites allow Internet users to submit questions via e-mail to virtually any type of medical professional. For instance, at RiteAid.com, users can sub-mit questions to pharmacists and receive a response within 48 hours, at no charge. At Mediconsult.com, Internet users can select from a list of professionals, provide detailed personal medical information by completing questionnaires, and obtain a comprehensive report in two to five days that includes treatment op-tions and suggestions, all for a fee of $195.

IT'S NOT ALL TALK

A growing number of Americans use the Internet to conduct banking and other financial business and to shop for a vast range of products. Consumers who conduct business and shop online value convenience, privacy, and control over their environment. Providers benefit not only by meeting these consumer needs and strengthening customer relationships but also through operational efficiencies. Consequently, consumers often receive financial incentives or other rewards for conducting transactions over the Internet.

Just as nontraditional sources meet much of the consumer demand for health care information on the Internet, many online health care shopping opportunities are being provided by industry newcomers. Soma.com (recently acquired by CVS), Drugstore.com, GreenTree.com, and PlanetRx have made highly visible launches providing online access to health and beauty products and prescriptions. These and other companies also may be positioning themselves to provide comprehensive prescription drug services once regulatory and business challenges are addressed.

PROVIDERS LAG ONLINE

Although some leading health care industry organizations, such as Johns Hopkins, Kaiser Permanente, Aetna U.S. Healthcare, and the Mayo Clinic, made large, early investments in establishing a relationship with the online consumer, traditional health care organizations generally have been slow to embrace the Internet. Media-based companies such as Time, Inc., and America Online have led in generating traffic at their health care sites, and many new online companies have been formed to capitalize on consumer interest and meet demand for health care information. So many health care sites of such disparate quality exist that new online services provide evaluations of medical sites.

Physicians, too, lag behind their patients in using the Internet. In the 1997 Health Care Outlook Survey produced by the Institute for the Future, most physicians reported seeing patients who had used the Internet to investigate their diseases, but only 22% would recommend that patients seek such information. Many articles and survey findings report that physicians are increasingly frustrated in their dealings with patients armed with materials pulled from the Internet-in particular because visits with these patients, whose research may include misinformation as well as valid data, are excessively time-consuming.

Some traditional health care companies are responding to consumer interest in using the Internet for transacting business. Kaiser Permanente members can schedule physician appointments online, Prudential members can enroll in health programs, and several major drug chains and prescription mail service providers allow online submission of prescription refill requests.

Pharmaceutical benefits managers (PBMs), who historically have been fo-cused on payors rather than consumers, are beginning provide consumer transaction processing opportunities. Cobranded with payor clients, the new PCS member site, PCSRx.com, allows members to re-ceive their personal prescription history securely, as well as order prescription refills for mail delivery.

IMPLICATIONS FOR MANAGED CARE PHARMACY

The Internet is a communication channel with distinctions that must be understood not only to build an effective Internet application but also to appreciate how it can broadly influence consumer expectations and behavior.

The Internet user is in charge. In an impersonal milieu, the Internet user can self-deliver very personalized service. He or she chooses what to retrieve, and at what pace. Internet users can execute rapid, focused searches of vast information and obtain highly tailored responses.

The economics and regulation of traditional print and broadcast media create a quality filter of sorts, but in the Internet world, barriers to publication are very low. With no similar Internet filter, the user is exposed to information the quality of which may range from excellent to abysmal.

All these factors affect how the Internet will change-and in fact, is changing-the operating environment for managed care pharmacists:

Significant, increasing consumer health care research has resulted in the emergence of the highly informed-and the confidently misinformed-consumer. Educational materials from traditional health care providers, including pharmacists, must reflect an understanding of this trend by providing greater depth and breadth of information. Pharmacists must be prepared to address misconceptions about certain drugs, diseases, and alternative therapies.

Although more consumers are using the Internet to supplement their health information, this trend is not universal. The gap is widening between the highly informed consumer and the consumer who does not use the Internet. Programs and communications targeted to the consumer must accommodate this increasingly wide variation in consumer knowledge.

The wide variance in quality of information found on the Internet has increased skepticism among some consumers, who find themselves unsure of who or what to trust. Managed care pharmacists must ensure that their plans maintain credibility with consumers and build brand-name recognition for integrity and expertise.

Virtual communities of consumers with specific health care concerns create ideal environments for the growth of activism. Consumers will increasingly challenge and resist benefit changes that they perceive as restricting their options and rights. Managed care must be prepared to address these concerns whenever considering changes in formularies and pharmaceutical benefits.

The ability of consumers to perform high-speed, tailored information searches on the Internet has raised their expect-ations of service. Consumers wanting information designed to meet their personal needs will more often reject mass-marketed products and services. This level of expectation requires that managed care develop highly targeted communication programs, including online intervention capabilities.

The early entry of nontraditional organizations into the Internet health care market may require managed care to explore business relationships, roles, and partnerships with these providers, especially those that enjoy the confidence of consumers.

Online processing has given consumers a fast, easy option for routine business transactions. Managed care pharmacists can expect that more consumers will come in for face-to-face assistance or use call centers to talk directly with a pharmacist when they need help with more complex issues.

The Internet represents just one of the more visible changes that are affecting the managed care pharmacy environment. But just as the Internet presents challenges, it also offers opportunities for managed care pharmacists to meet consumer needs. Innovative managed care organizations will recognize these opportunities and take advantage of them. New players in the market will continue to emerge, and new roles will emerge for existing organizations. The successful managed care pharmacist will be in the forefront of practitioners who recognize and adapt to the changes that result from the Internet revolution.