Kanter GP. COVID-19 and the Future of Drug Marketing. JAMA Health Forum. Published online September 8, 2020. doi:10.1001/jamahealthforum.2020.1081
Earlier this year, the Department of Justice announced that Novartis agreed to pay $678 million to settle claims that it gave kickbacks—such as roundtables at Hooters and speaker payments for fake events—to induce doctors to prescribe Novartis drugs. The admission that many so-called educational events were in effect bribes was perhaps shocking but not surprising to those working in health care,1 some of whom had long given up on ever containing the excesses of drug marketing.
In its own announcement of the settlement, Novartis declared—as one does in these situations—that these marketing activities were relics from an earlier vintage of the firm. Under new leadership, Novartis was moving away from speaker programs and “embracing new, digitally enabled education programs,” ie, online medical education. While Novartis may not have had much of a choice in its embrace, it was hardly alone in its online transition. With stay-at-home orders and social distancing, COVID-19 has thrown the standard drug marketing playbook of free dinners and clinic drop-ins into disarray.2
For critics of traditional pharmaceutical marketing, some changes wrought by COVID-19, such as strict restrictions on access to clinics and hospitals, have been welcome. Other changes, however, carry additional risks. The upheavals brought about by COVID-19 have led to growth of telehealth and other services that have been advances in how health care is delivered. These changes also present an opportunity to reset the boundaries and norms for physician-industry interactions. As clinics and hospitals, as well as drug and device firms, regroup, policy makers, physicians, and patients should be intentional in re-establishing rules for doctors’ engagement with industry.
One unintended consequence of health care’s response to the pandemic is that visitor restrictions to care facilities, intended to protect patients’ families, has also limited access for people who didn’t really have a good reason to be there. Sales reps no longer have casual access to physicians and are forced to make online appointments to talk about their products. Free meals can no longer lubricate sales pitches. Clandestine conversations about off-label uses become rather less stealthy when they have to be conducted by video. The drubbing to drug promotion caused by COVID-19 lockdowns have been so severe that sales from at least 16 drug launches, according to one pharma consulting group, are thought to be at risk. And at least one CEO has attributed his company’s disappointing drug launch to disruptions in contact with prescribers.
Other shifts in promotional activity will be more ambiguous in their impact. The switch to video meetings and online presentations has made drug promotion far less costly for companies—no travel expenses for sales reps and doctors, no fine dining events, and low fixed costs of producing video content that can reach a large audience. History and economics tell us that the lower the costs of doing something, the more firms will engage in it.
In addition, now that remote working has dissolved the boundaries between home and office, sales reps can reach doctors in their homes, at all hours, ratcheting up the intensity of exposure to product messaging. Increased use of smartphone and tablet apps to engage physicians (e-detailing) create greater risks of unwanted collection of data on physicians’ private information and phone activity.
And as webinars become a popular mode of promotional activity, it may be more difficult for physicians to distinguish between educational content and marketing content unless there are clear rules of engagement for this format.
Over the past 20 years, there have been multiple attempts to enact regulations that circumscribe promotional activity directed at physicians.3 Most have been unsuccessful. The few that have been implemented have mostly nibbled around the margins.
The Open Payments provision in the Affordable Care Act that requires drug and device companies to report payments that they make to physicians has made flows of money more transparent. But total industry payments have actually increased since public disclosures were required. Amendments to anti-kickback statutes have raised penalties for infractions, but final settlement amounts have been relatively puny. In the recent Novartis agreement, for example, the amount paid by Novartis constituted 1.4% of its previous year’s net sales and 0.05% of its market capitalization. Any hoped-for deterrence effects, if they are happening at all, are likely on the scale of microns.4,5
In strangling traditional drug marketing, COVID-19 has, quite by accident, done what policy makers have for decades been unable to do. And just as the COVID-driven involuntary adoption of telehealth has led some providers to reassess the clinical value of some types of in-person office visits, so too should the severing of face-to-face industry contacts lead to re-evaluating whether much is lost by abandoning in-person sales visits.
With the shift to digital promotion and detailing, policy makers should update their regulatory approaches. With video meetings and webinars, a quick mouse-click can record and document interactions. Firms could be required to record their virtual contacts so that institutions and regulators can periodically monitor interactions and content. Regulators could permit or even require the presence of a competitor to observe firm-sponsored digital events to enhance the market’s own internal discipline. New guidelines could be issued on the advertising of webinars to help physicians distinguish between purely promotional events and educational events. And new rules could be enacted to regulate the access that pharma e-detailing apps have to providers’ smartphones.
Physicians and patients should not be passive actors during this transition, either. Physicians uncomfortable with saying no during in-person sales interactions should use their control of technologies to set stronger boundaries on their time. Those who engage with sales reps and industry content through their smart devices should be vigilant of the permissions they grant to these industry-supported apps. And patients who are too intimidated while in the examination room to ask their doctors about their ties to drug companies can lean on the safe distance of email to get the information they need.
As the health care system adapts, so will the drug, device, and other industries that support and recast it.6,7 So, too, must regulators and all of us who have a stake in our nation’s health and the integrity of its health care system.
Corresponding Author: Genevieve P. Kanter, PhD, Division of General Internal Medicine, University of Pennsylvania, Blockley Hall 12th Floor, 423 Guardian Drive, Philadelphia, PA 19104 (firstname.lastname@example.org).
Conflict of Interest Disclosure: None reported.
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