Games vs. Mobile Health Monitoring Devices: Which is a Better Motivator?

Games vs. Mobile Health Monitoring Devices: Which is a Better Motivator?

What could possibly justify spending $8,000 for an electronic mobile ultrasound device vs. $100 for a stethoscope? Keep in mind that the stethoscope will likely last a lifetime, whereas the electronic device -- like my son's iPod -- may last only a couple of years before failing or becoming obsolete even sooner.

"Why would I listen to 'lub dub' when I can see everything?" said a doctor quoted in today's Wall Street Journal (see "Can Mobile Monitoring Devices Improve Medical Treatment?"). "Dr. Topol, a cardiologist in San Diego, carries with him instead a portable ultrasound device roughly the size of a cellphone [see image]. When he puts it to a patient's chest, the device allows him to peer directly into the heart. The patient looks, too; together, they check out the muscle, the valves, the rhythm, the blood flow."

Doctors, especially cardiologists, are notorious gadget geeks, so you have to take their enthusiasm for electronic devices with a grain of salt, especially when they claim that the devices will improve health care.

"[Dr. Topol] and other physicians say the technology can not only improve diagnoses and treatment, but also revolutionize how doctors and patients think about health care. Mobile tools allow physicians to monitor vital signs, note changes in activity levels and verify that medications have been taken, without ever seeing a patient face to face."

I wasn't aware that physicians were even interested in "verifying that medications have been taken" let alone that they would buy expensive devices to help them do that. Most physicians don't want to take on that responsibility and be legally liable. Also, who will pay for the service, especially when the physician makes a substantial investment in devices? The same goes for "monitoring vital signs" and other forms of monitoring patients from afar. "We're getting virtual touch, rather than actual touch," says Dr. Topol.

Dr. Topol "found that many [of his] patients are more willing to make lifestyle changes that keep them healthy when they can monitor the consequences of their actions in real time. A doctor can talk 'until he's blue in the face,' he says, but it sometimes takes cold, hard data to motivate a patient."

Social gaming enthusiasts disagree. "We tried to give people constant feedback about [patients'] health, but for a lot of people, more bad news and negative feedback just didn't work," said Adam Bosworth, the chief technology officer at Keas Inc., whose clients include Pfizer Inc. and Novartis Inc. "If you keep giving someone negative feedback, they will eventually change the channel to the game channel. One day we decided to become that game channel." Bosworth was quoted in another Wall Street Journal article published today (see "Health Care Social Gaming Start-Ups").

So, which technology is better for helping people change their lifestyles and improve their health? Social media games or remote monitoring devices?

Which technology is better at helping change behavior & improve health?
	Mobile social gaming apps
	Mobile remote monitoring devices
	Both are effective.
	Neither are effective.
	I don't have a clue!

FDA Social Media Guidelines May Be Moot If This Court Decision Holds Up

FDA Social Media Guidelines May Be Moot If This Court Decision Holds Up

Drugmakers dissatisfied with the FDA’s use of guidances as a form of policymaking -- including long-awaited guidance for use of social media by the pharmaceutical industry -- could find legal ammunition against the practice in the case "United States of America v. Franck’s Lab," which is pending appeal in the U.S. Court of Appeals for the Eleventh Circuit.

I noted before that the drug industry may be arraying its legal forces to derail the issuance of social media guideline (see "Pfizer Asks for New FDA Regulations, Not Guidance, for Social Media" and "Pharma Turns Up the Heat on Off-Label 'Free Speech' Chilled by FDA - Implications for Social Media Marketing").

The ruling being appealed is that FDA does not have authority to enjoin the "long-standing, widespread, state-regulated practice of pharmacists filling a veterinarian’s prescription for a non-food producing animal by compounding from bulk substances." What can this possibly have to do with social media guidances?

According to a recent Washington Legal Foundation (WLF) "Backgrounder" (see "Court Ruling - If Upheld - Casts Doubt on FDA's Use of Guidance Documents"), "While Franck's case involved pharmacy compounding of bulk pharmaceuticals in non-food producing animals, its implications extend broadly to other areas of FDA law, particularly as it relates to FDA’s increasing use of guidance documents to expand regulatory requirements. In the past year, FDA has issued dozens of important draft guidance documents and final guidance documents, while releasing very few significant regulations. Given FDA’s penchant for issuing guidance documents instead of proceeding through notice and comment rulemaking, the court’s decision may have broad applicability concerning FDA’s ability to regulate or enforce its laws through guidance instead of rules. Indeed, FDA often applies draft guidance documents as if they represented binding obligations. It sometimes even references the contents of the document in communications with industry before the document is finalized."

WLF points out another reason the drug industry prefers rulemaking over guidance: "When FDA issues guidance documents," says WLF, "it tends not to acknowledge the negative comments. The agency typically offers no explanation for why it has opted to stick with its proposed language, rather than making changes to address adverse comments. This failure to respond to comments is not permitted for agencies when they engage in rulemaking [my emphasis]."

This lack of response to comments is a significant factor for social media guidance. The FDA held a public hearing and requested comments on the social media regulatory issues it proposed to write guidance for. Many, many comments were submitted (see "Answers to FDA's Questions Regarding Pharma's Use of Social Media") and so far the FDA has remained mum regarding these comments and may even do so when -- and if -- it publishes more social media guidelines. The recent off-label guidance (see "FDA Guidance on Responding to Unsolicited Requests for Off-Label Information Via Social Media") also did not refer to any comments the agency may have received.

"If the district court's ruling is upheld," says WLF, "its analysis on FDA’s use of guidance documents is likely to be cited in other FDA proceedings and legal challenges testing the agency’s right to enforce through guidance in lieu of regulations."

P.S. I note that the court case in question involved the death of several ponies due to a compounding error! PONIES! Lucky that it wasn't PEOPLE because I'm sure the court would not be so callous as to strike down FDA's rights in that case.

[Hat Tip to Darshan Kulkarni (see @FDALawyers and website) for providing information about this case.]

2011 in Images from Pharma Marketing Blog

2011 in Images from Pharma Marketing Blog

These are my favorite images that appeared in Pharma Marketing Blog posts made in 2011. Enjoy and have a Happy New Year!

Pharma Marketing Blog: The Year 2011 in Images

View more presentations from Pharmaguy

FDA Guidance on Responding to Unsolicited Requests for Off-Label Information Via Social Media

FDA Guidance on Responding to Unsolicited Requests for Off-Label Information Via Social Media

Yesterday, while most of us were still on vacation, the FDA quietly issued without fanfare -- ie, no press release telling us about it or how to submit comments -- "Guidance for Industry Responding to Unsolicited Requests for Off-Label Information About Prescription Drugs and Medical Devices." You can find the document here.

Section VI. of this guidance addresses responding to unsolicited requests on public forums such as the Internet. While this may not be the "social media" guidance many people were expecting (see "First FDA Social Media Guidance to Address Responding to 'Unsolicited Requests' for Off-label Information"), it does include guidelines for responding to unsolicited requests for off-label information encountered through "emerging electronic media."

As with all guidances, FDA warns "Firms may choose to respond to unsolicited requests for information about off-label uses of their approved or cleared products in a manner other than that recommended in this draft guidance. Such activity would not constitute a per se violation of the law, but could potentially be introduced as evidence of a new intended use." Some drug companies (eg, Pfizer) would have preferred new legally-binding regulations rather than guidelines (see, for example, "Pfizer Asks for New FDA Regulations, Not Guidance, for Social Media"). The industry might also challenge these guidelines on legal grounds (see, for example, "Pharma Turns Up the Heat on Off-Label "Free Speech" Chilled by FDA - Implications for Social Media Marketing").

Aside from pressure by the drug industry, FDA felt the need to issue this guidance because it "recognizes that it can be in the best interest of public health for a firm to respond to unsolicited requests for information about off-label uses of the firm’s products that are addressed to a public forum, as other participants in the forum who offer responses may not provide or have access to the most accurate and up-to-date information about the firm’s products." I'm not sure I agree with that because there have been a number of surveys that indicate physicians (as well as the general public) have several other preferred sources of drug information (see, for example, "Are Pharma Reps Important to Docs or Not?"). But let's leave that issue aside for now.

Let's take a closer look at how these guidelines apply to social media such as Youtube, Blogs, and Twitter.

The guidelines break out responding to PRIVATE and PUBLIC requests for off-label information. As for handling private requests, the guidelines pretty much reiterate what the drug industry already knows. The section regarding public requests, however, is what will be of most interest to the industry. Social media is in the this category.

Youtube and Solicited Requests
The guidelines have something interesting to say about videos posted on Youtube.  Specifically, it warns about responding to public comments that may be received in response to videos that a pharma company may encourage people to post about about their own uses of the company's product. FDA gives this example:

"A firm asks or otherwise encourages users to post videos about their own uses of its product on third-party video-sharing sites (e.g., YouTube), which may result in video postings about an off-label use of its product. If the firm’s initial request for posting of videos results in any questions about off-label uses, or if any off-label video posting made in response to the firm’s 1encouragement of video postings results in questions about the product’s off-label use, these questions would be considered solicited requests."

FDA considers requests for off-label information that are prompted in any way by a manufacturer or its representatives to be solicited. If a company responds to such "solicited  requests," it must be careful because such responses  "may be used as evidence of a new intended use. Introducing a product into commerce for such a new intended use without FDA approval or clearance would, under these requirements, generally violate the law."

Is this guidance enough to encourage pharma companies to open up comments on their Youtube pages?

I doubt it. Most pharma companies are still waiting to know how they should respond to potential adverse event reports they may receive via comments before they venture into opening up comments on Youtube. It's not even likely that pharma companies will engage in branded Youtube projects in the first place, although there has been a precedent (see "Novartis Attempts Perfect Execution of Web 2.0 Trick!").

Of more interest to me are the examples FDA gives for how drug companies should respond to "unsolicited" requests via social media.

Blogger Example of "Solicited Request"
FDA cites this example: "If a firm sends out packets of information to known bloggers or online consumer reviewers and encourages them to write about an off-label use of its product on third-party sites and this then provokes a discussion about that off-label use, any requests inquiring about the product’s off-label use as a result of these blogs, whether posted as comments to the third-party site or directed to the firm, would be considered solicited requests."

Although I have never heard of a pharma company ever "encouraging" bloggers to write about off-label uses, I do know that some companies have invited bloggers to vacation sites (see "A Call for Pharma Social Media Transparency Guidelines for Patient Bloggers"). What they discuss behind closed doors is not known to me or to the FDA unless there is a blogger "mole" present.

So, how would FDA prove that the company "encouraged" off-label discussion?

One way is to examine the contents of the "packets of information" sent to the bloggers. If that packet includes off-label information, then FDA can make a case that the company encouraged the blogger to write about it.  (See "BI Masters the Art of WOM through Its 'Parrots,' er, Spokespersons" for a similar situation involving BI). The guidelines do NOT get into this level of detail, which is unfortunate and supports industry's claim that FDA guidance is often "unclear." I'm sure this will be a topic covered by comments to the FDA regarding this guidance.

Twitter Example of "Solicited Request"
FDA cites this example: "If a firm announces results of a study via a microblogging service (e.g., Twitter) and suggests that an off-label use of its product is safe and effective, any comments and requests received as a result of the original message about the off-label use would be considered solicited requests."

Many pharma company Twitter accounts have been used to announce results of studies related to unapproved uses of Rx drugs. Some such tweets may have made efficacy claims, but I am not aware of any that claimed the product was "safe." I am not sure from reading the guidelines how FDA would view such tweets.

How should pharma respond to unsolicited requests received via public Internet sites and social media?

FDA puts limits on how to respond to such requests on public sites. FDA is concerned that product information "posted on websites and other public electronic forums is likely to be available to a broad audience and for an indefinite period of time [and] that firms may post detailed public online responses to questions about off-label uses of their products in such a way that they are communicating unapproved or uncleared use information about FDA-regulated medical products to individuals who have not requested such information. In this circumstance, communications to persons who have not requested information may promote a product for a use or condition for which FDA has not approved or cleared. FDA is also concerned about the enduring nature of detailed public online responses to off-label questions because specific drug or device information may become outdated (e.g., new risk information may become available)."

In general, FDA's position is that "a firm’s public response to public unsolicited requests for off-label information about its named product should be limited to providing the firm’s contact information and should not include any off-label information."

That eliminates a "loop hole" I often worried about; namely, an anonymous agent of a pharmaceutical company can post a request for off-label information and initiate a discussion that includes information posted by the pharmaceutical company itself.

FDA suggests that a drug company handle such public requests through private channels after the requester follows up to the contact provided with a private request that will then be handled "offline."

FDA says:

• The firm’s public response should convey that the question pertains to an unapproved or uncleared use of the product and state that individuals can contact the medical/scientific representative or medical affairs department with the specific unsolicited request to obtain more information. 
• The firm’s public response should provide specific contact information for the medical or scientific personnel or department (e.g., e-mail address, telephone number, facsimile) so that individuals can follow up independently with the firm to obtain specific information about the off-label use of the product through a non-public, one-on-one communication.

Does It Serve the Public Interest?
Regarding responding to public requests; eg, via social media, FDA says "any substantive communication about off-label uses for the product, in response to the original unsolicited off label question, should occur solely between the firm and the individual who made the request," says FDA. "Regardless of the fact that the original, unsolicited off-label question may have been available to a very broad audience, the firm should not make its detailed response with off-label information publicly available within the same forum."

Unfortunately, although this may close the "loop hole" I mentioned above, this method of responding individually has a couple of negative implications:

1. First, private responses may not serve "the best interest of public health" because "public" means a bunch of people, not one person at a time. On the one hand, FDA believes responding to unsolicited requests for information about off label uses of the firm’s products serves the public interest because the firm has "robust and current information about their products." On the other hand, firms cannot distribute this information "publicly."
2. Responding privately requires more resources and expenses. Many people over the course of time may have the same questions. Instead of being able to use the power of the Internet to answer all these questions in a single message, each must be handled separately.

Sales and Marketing May be Seen, but Should NOT Be Heard From!
However the response is made, the FDA believes that "Responses to unsolicited requests for information should be generated by medical or scientific personnel independent from sales or marketing departments. FDA recommends that medical or scientific personnel have specialized backgrounds in responding to unsolicited requests for information, including important training, such as appropriately narrowing questions, tailoring responses only to the specific questions being asked, providing unbiased responses, and properly documenting responses.

"By contrast," says FDA, "because sales and marketing personnel are focused by training and experience on promoting a firm’s products, FDA recommends that sales and marketing personnel have no input on the content of responses to unsolicited questions or requests for off-label information."

There are more nuggets of information in this guidance that I haven't covered here. I look forward to the comments form the drug industry itself.

Webicina's "Open Access" Social Media Guidelines for Pharma

Webicina's "Open Access" Social Media Guidelines for Pharma

Health Social Media advocates abhor a vacuum, especially when the vacuum is caused by the lack of FDA guidelines for use of social media by the pharmaceutical industry. To fill that vacuum, several more or less independent 3rd parties are developing guidelines for the industry in the hopes of spurring the FDA to eventually do the same or to bypass the new for FDA guidelines altogether.

In the U.S., the Digital Health Coalition (DHC) is in the final stages of developing its "Social Guiding Principles," which is being shared with members of PhRMA who have expressed interest in the project. DHC's 7 dwarf-sized principles have been making the rounds to a select group of insiders and will be made public at the ePharma Summit in NYC this February (perhaps on my birthday!). See the PMN Conference Calendar for a link to the summit.

Another 3rd-party (ie. Peter Pitts) version of social media principles for pharma was previously reviewed by me (see "Deconstructing Pitts' Guiding Principles for Pharma Social Media"). Pitts created 11 principles. However, many of these principles may be very similar to the DHC ones if only because Peter Pitts worked with DHC.

Just recently, a third set of 3rd-party social media principles was released by my friend Dr. Bertalan Mesko (better known as @Berci), the founder and managing director of Webicina.com. These "open access" social media guidelines for pharma, which you can find here, were written by an adhoc editorial board of social media advocates with suggestions from "hundreds of collaborators." The authors are @Berci, Dr. Felix Jackson (@felixjackson), Silja Chouquet (@whydotpharma), Andrew Spong (@andrewspong), Denise Silber (@health20paris), and Rob Halkes (@rohal). It is a distinctly European group of experts, who hope their effort will "facilitate the process for the FDA of publishing its own guide."

Unfortunately, I don't think the FDA will be looking to an "open access" document for ideas. Also, in my opinion the "open access" SM guidelines, like the other two 3rd-party documents mentioned above, are much too vague to be of any use to the FDA. Still, I'd like to review the Webicina guidelines and see how they might be used by the pharmaceutical industry.

The Webicina document breaks down the guidelines into the following 8 categories:

1. A Physician’s Rules of Engagement 
2. Pharma’s Rules of Engagement 
3. How pharma should use social media 
4. How pharma should use Wikipedia 
5. How pharma should use Facebook 
6. How pharma should use Twitter 
7. How pharma should write blogs 
8. How pharma should use Youtube

Obviously, a lot of these "How To's" -- such as "speak plainly" and "be helpful" -- are not in FDA's bailiwick or not specific enough for FDA regulatory guidelines. I'll just look at what I think are the most interesting aspects of these guidelines, whether or not they are useful to the FDA.

Can Social Media Replace Face-to-Face Sales Rep and Physician Contact?
Under "Pharma’s Rules of Engagement," is included a few guidelines on how pharma should interact with medical professionals. It states, for example, "A private social media message is often as good as a face to face talk." In this context, I assume "face to face talk" means a visit by a pharmaceutical sales rep. Of course, personal contact between people will never be completely replaced by social media contact, but I can see how social media can save time and money if sales reps could communicate with physicians other than via office visits, which are pretty limited in the EU compared to the U.S.

But should pharma sales reps have their own Twitter accounts and should physicians "follow" these accounts and vice versa so that reps can DM (direct message) their physician clients? Maybe it would work. I'm sure that physicians would prefer short 140-character Twitter DMs over long email blasts! And these days, much commercial email ends up in the spam folder never to be opened!

People to People, Not Company to People Communication
Another suggestion put forward in this document is that when pharma companies use social media, they should "Be human. Ensure that you engage with people as people." I am an advocate of that idea and have been trying to "out" the humans who are working in pharma and who are using Twitter (see "More Pharma Social Media Pioneers Recognized"). But many pharma social media activities are completely non-personal and try to use the brand or company name as something real people will communicate with! It's not always easy to see who is "behind the curtain" and posting tweets or comments on Facebook. Sometimes, phony people are used to make the conversation seem more personal (see, for example, "Was Lilly's #mmeds Twitter Chat a Discussion or a Press Conference?"). That, of course, violates the main principle mentioned again and again in the Webicina document "Be transparent. Clearly state who you are and what your intent is."

For Facebook, the Webicina guidelines state: "Be clear: Provide information about the company with contact details and clearly state who publishes comments on behalf of the company. People prefer talking with a real person, not a brand or a company."

I see a problem with pharma companies getting too personal and allowing the person behind the curtain to be too visible. First, some companies (eg, Pfizer) claim that they do not have any people (FTEs) dedicated to social media. Several people may share the responsibility of posting tweets, for example. People also leave one company and join another. Nevertheless, I have given my Pharmaguy Social Media Pioneer Award to real people behind the curtain, not the company (see, for example, "AZ's Tony Jewell Receives 2nd Annual Pharmaguy Social Media Pioneer Award"). I just hope that it helps them when they look for a job with a competitor's company :-)!

Enable Comments, Don't Moderate?
The issue of comments on pharma social media sites is very problematic for the industry, which often cites regulations for why comments are turned off on sites like YouTube and until recently on Facebook. We've seen a number of instances where a pharma company has gotten in trouble because of  comments (most notably on Facebook; see, for example, ' "Disgruntled Patient Shuts Down sanofi-aventis Facebook Page").

The Webicina guidelines, however, prefer that comments be enabled "where possible" (whatever that means). Furthermore, this principle of avoiding comment moderation is reiterated several times in the guidelines: "Avoid moderation. If you have to moderate, try not to pre-moderate and clearly state what you will moderate and why. Publish your moderation policy."

Pre-moderation, which the Webicina guidelines say may be OK fo blogs, is probably not something many pharma companies have the resources for managing. It may be something that is outsourced, though. Right now, however, it is an extra-added expense that many companies do not wish to have. Several comments form the industry to FDA's call for answers to its questions about social media favor post-moderation over pre-moderation (see "Answers to FDA's Questions Regarding Pharma's Use of Social Media").

Another, related principle: "Avoid editing comments. Do not edit the comments you moderate as it changes the meaning. People don’t like this. Remove the comment and explain why." This was another topic covered in comments to the FDA (op cit). It took less than 48 hours for Pfizer to explain why it deleted certain comments on its Chapstick FB page (see "Pfizer's Facebook Fiasco: Chapstick Slapstick Ad Uses Woman's Ass as a Prop"). That wasn't fast enough, however, to prevent a social media "death spiral" as reported by AdWeek.

Stop When Finished. Is a Campaign Socially Acceptable?
One interesting principle espoused by the Webicina guidelines is "Stop when finished. Close finished campaigns and redirect people to other places." In some pharma pundit circles, mentioning "campaign" and "social media" in the same sentence is as taboo as saying social media is "just another channel." Recently, I've criticized some pharma companies for abandoning their Facebook "friends" when new rules about comments were put in place (see "Pharma Facebook Pages Being Phased Out: A Good Run While It Lasted! Did Facebook Kill the Beast?").

I can see why pharma marketers prefer a campaign with a beginning and an end. They have specific budgets and must achieve a specific measurable goal (e.g, increased market share) within a certain time frame. There are other patient and physician needs that pharma can meet via social media that are NOT compatible with such a campaign mentality. Needs such as how to find affordable medicines, how to get more information about adhering to the treatment and other support issues. It's not clear who within a pharmaceutical company is charged with meeting such needs or if there is a budget outside control of the brand team for such things.

Wikipedia Editing Rules
On at least one occasion, a pharmaceutical company was caught editing a Wikipedia page about one of its products in order to gloss over some negative studies (see "Web 2.0 Pharma Marketing Tricks for Dummies"). @berci is an expert regarding publishing health information on Wikipedia, so I would take his advice (as it appears in the Webicina guidelines) seriously.

One Wikipedia editing guideline suggested is this: "Do not promote. Do not edit an article to promote your medicine." It may not be so easy to determine if the edit was done to help promote the product or to "correct misinformation." One person's idea of "misinformation" may differ from another person's -- especially if the other person is a marketer. Selectively adding only positive information (eg, positive results from new clinical trials) can be considered promotion -- in fact, it's what PR people (who are the pharma people in charge of social media activities) do all the time to "promote" their products.

Webicina offers a better Wikipedia editing principle for pharma: "Suggest edits. Suggest edits on the Discussion page for other editors to make. But you still need to be transparent about who you are and explain your rationale."

Rules for Twitter
Webicina et al have a couple of interesting rules for how pharma companies should use Twitter.

"Select your audience. Use different accounts for different audiences so that people can follow content which is tailored and appropriate for them. Examples include investors, shareholders, journalists, job seekers, patients and customers."

I haven't seen many pharma companies with multiple Twitter accounts, although I am sure there are a few. Some companies (e.g., Pfizer) may have different Twitter accounts in different countries. But most pharma Twitter accounts are corporate communications accounts that push out information to all the above-mentioned audiences in all countries. I haven't seen any that are just for patients, for example.

"Publish more than 140 chars. Use longer messages with services like Twitlonger to include additional information."

This is a good idea and one that I suggested some time ago (see "Breaking the 140-character Limit of Twitter Opens the Door to FDA-Compliant Branded Tweets"). I pointed out that this technique can allow pharmaceutical companies to make branded Tweets that will pass muster with the FDA. The "additional information" could be used to mention the brand name as well the important side effects as required by the FDA. However, I don't see this technique being widely adopted by any of the people or companies I follow on Twitter. I don't even bother with it myself.

You're Mad if You Don't Use Youtube
That's what the authors of the Webicina social media guidelines think, mostly because Youtube "generates the world's second largest number of searches after Google itself." Of course, that has nothing whatsoever to do with the merits of Youtube as a social media platform/channel or whatever. I have often said that pharma's interest in social media such as Facebook and Youtube has more to do with search engine visibility than with engaging in conversations (see "Drug Companies Are Flocking to Facebook for Eyeballs, Not Conversation").

It doesn't take a genius (or guidelines) to understand the appeal of Facebook, Youtube, and other social media platforms. This is where the "eyeballs" are as demonstrated by this chart from the 2011 PwC Health Research Institute Survey (click on the chart for an enlarged view):

I'm not surprised by the percent of consumers who have used Facebook, Youtube, and blogs to get health information, but I am bewildered by the "fact" that more people have used Google+ than Twitter for this purpose. I thought Google+ was dead in the water as a useful social media alternative to Facebook or Twitter. It could be that people chose Google+ meaning Google search because the latter was not an option in the survey. But I can see it now! There will be a rush to Google+ by pharma marketers in order to get in on the ground floor of another social media eyeball fest! In fact, I have heard that some companies are reserving Google+ account names without yet having any specific plans for how they will use it!

Proposed Rules for Physician Payment Sunshine Act: Some Clouds on the Horizon

Proposed Rules for Physician Payment Sunshine Act: Some Clouds on the Horizon

The Centers for Medicare and Medicaid Services (CMS) released their proposed rule for the Physician Payment Sunshine provision of the Affordable Care Act (see "CMS Releases Proposed Physician Sunshine Act Regulations", where you can also download the proposed rule). Because CMS was late issuing this rule, the drug industry will NOT have to begin data collection on Jan. 1, 2012, as "required" by the Sunshine provision, and will not need to begin data collection until final regulations are issued. Final regulations come AFTER comments on the proposed rule are accepted through Feb. 17, 2012.

That means that only PART of the 2012 payments may be submitted on Mar. 31, 2013 and available for public scrutiny by Sep. 30, 2013.

It's possible, however, that CMS may be further delayed if the comments received are plentiful and difficult to respond to before the agency issues the final rule.

Of course, pharma companies by now should be ready to begin data collection by January 1, 2012. Which means that they could theoretically submit a full year's (2012) worth of data regardless of the timing of the final rule. CMS said "we recognize that some manufacturers and GPOs may begin to collect certain data voluntarily." How many companies, however, will do this when they can claim they were waiting for CMS? It's just another test of willingness of the industry to be pro-actively transparent and open.

Also, CMS is seeking comments "on the amount of time applicable manufacturers and applicable GPOs will need following publication of the final rule in order to begin complying with the data collection requirements." I anticipate that many comments might cite CMS's estimate of 90 days to be too little and request more time. Thus, we may not see any 2012 data at all!

CMS's Tardiness in Issuing Sunshine Act Rule May Mean We'll See No 2012 Data!
"Finally," says CMS, we also seek input on specific challenges that applicable manufacturers and applicable GPOs may face when setting up the necessary data collection and reporting systems."

This is the Achilles' Heel that may mean that we will not see any 2012 data at all! If drug and device companies cite significant challenges that CMS's final rule must mitigate, that could delay issuance of the final rule or significantly limit how the information is reported. The industry may claim, for example, that it is "challenged" to breakdown payments into specific categories and ask that payments be lumped into larger, more encompassing categories. This would make it more difficult to analyze the data to see exactly what physicians are being paid to do, especially research versus marketing assistance.

Here are some other tidbits from CMS's proposed rule:

Foreign Drug Companies Must Also Report Payments
CMS proposes that any drug or device company that sells or markets products in the U.S. are subject to the rule regardless of where their corporate headquarters are located. Thus, says CMS, "Under this definition, manufacturers of a covered drug, device, biological, or medical supply are deemed to be an 'applicable manufacturer' if their products are sold or distributed in the United States (U.S.), regardless of where the covered drug, device, biological, or medical supply is actually produced or where the entity is actually located or incorporated... The opportunity for undue influence or inappropriate relationships caused by payments or transfers of value to covered recipients is the same for manufacturers of drugs, devices, biologicals, or medical supplies sold or distributed in the United States regardless of where the product is actually manufactured, and we, therefore, propose to treat them the same."

"Common Ownership" Loophole Closed
CMS wants to be sure that a wholly or even partially owned subsidiary of a drug or device company set up to dole out payments to physicians cannot escape the regulation. Such companies under "common ownership" -- as when "the same individual, individuals, entity, or entities, directly or indirectly, own any portion of two or more entities" -- "are also subject to the reporting requirements under this provision, even though they themselves may not be involved in the "manufacturing" process." CMS is seeking comments regarding its definition of "common ownership" to see if changes are necessary.

OTC Drug Manufacturers Excluded
CMS's proposed rule excludes manufacturers/marketers of drugs and biologicals that are considered "over-the-counter" (OTC) from being covered by the regulations. "We believe that this exclusion may be appropriate for manufacturers that manufacture only these products (and not also products which fall within the proposed definition of 'covered drug, device, biological, or medical supply'), since physicians and teaching hospitals have less influence over patients' choice of OTC products."

Perhaps physicians have less influence over patients' choice of OTC products, but they surely play a role in Rx-to-OTC conversions. They sit on FDA advisory boards, for example, which determine if an Rx drug can be sold OTC.

Identifying "Covered Physicians"
There is some confusion on how to uniquely identify physicians. There are more than one "unique identifier" for physicians. The law refers to a National Provider Identifier (NPI) number, which is required under HIPAA.

CMS states "We seek comments on what other unique identifiers could be used, including whether these unique identifiers are readily obtainable by applicable manufacturers."

CMS is also closing a loophole I noticed in data already being reported by some drug companies; ie, certain payments are reported to be made to institutions or organizations rather than to individual physicians. CMS proposes that "payments or other transfers of value provided through a group or practice should be reported individually under the name(s) of the physician covered recipient(s)."

Categories of Information to be Reported
This is probably the most important issue that needs clarification. CMS provides details of how data such as names, addresses, medical specialty, date of payment, etc. are to be reported.

Name of Drug: The Sunshine Law requires that manufacturers to report the name of the covered drug, device, biological, or medical supply associated with that payment, if the payment is related to "marketing, education, or research" of a particular covered drug, device, biological, or medical supply.

"In cases when a payment or other transfer of value is reasonably associated with a specific drug, device, biological, or medical supply, the name of the specific product must be reported," says CMS. "For example, if a sales representative takes a physician to dinner to explain the benefits of the applicable manufacturer's new product, the name of the product must be included since it was associated with the dinner."

The Multiple Drug Conundrum
If the payment relates to multiple drugs, only one drug needs to be named. CMS, however, does not mention how the named drug should be chosen.

As an alternative, however, CMS is considering "allowing applicable manufacturers to report multiple covered drugs, devices, biologicals, or medical supplies as related to a single payment or other transfer of value. Allowing the reporting of multiple covered drugs, devices, biologicals and medical supplies may be easier for applicable manufacturers since many financial relationships are not specific to one product only, but would make aggregating payments by product difficult. We seek comment on this approach."

I'm betting the drug industry would prefer the one-drug naming approach where they have the option to name the drug of choice. This could make it difficult to link specific payments to specific drugs or assign payments to specific drugs to "even out" the distribution, Say, for example, that a sales rep is responsible for promoting 2 drugs at a dinner meeting, but is given a physician payment budget that apportions 80% to just drug A. The total budget could be reported under drug B, thus diverting attention away from drug A. I think you get what I mean!

Nature of Payment - Nondisclosure of Assumptions Make an Ass Out You and Me!
This is important. The Sunshine Act lists the following categories of payment:

• Consulting fees. 
• Compensation for services other than consulting. 
• Honoraria. 
• Gift. 
• Entertainment. 
• Food. 
• Travel (including the specified destinations). 
• Education. 
• Research. 
• Charitable contribution. 
• Royalty or license. 
• Current or prospective ownership or investment interest. 
• Direct compensation for serving as faculty or as a speaker for a medical education program. 
• Grant. 
• Any other nature of the payment or other transfer of value (as defined by the Secretary).

CMS suggests that manufacturers explain the reasoning behind how they categorize payments (in a mandatory "assumptions document") since there may be significant differences among manufacturers on this issue. However, CMS will NOT make these"assumption documents" public because "they may contain information applicable manufacturers would consider proprietary."

That's a pretty big "transparency loophole," IMHO. Although CMS will monitor the assumptions, there is no way for the public to monitor CMS! The drug industry can be free to define these categories as it sees fit and not run into trouble unless different companies use wildly different assumptions and raise red flags at CMS. Also, the politically-appointed HHS Secretary may overrule the CMS as she did with the FDA!

Also, the CMS is seeking comments on whether or not the "assumption document" submission should be mandatory or voluntary! I can only guess what industry's comments will be about that!

One Category for ALL Speakers' Fees
CMS does, however, specify how manufacturers should interpret "Direct compensation for serving as faculty or as a speaker for a medical education program." CMS proposes that this category be "interpreted broadly to encompass all instances in which applicable manufacturers pay physicians to serve as speakers, and not just those situations involving 'medical education programs.'"

Under that rule, accredited CME programs would be lumped in with all other speaking activities, such as satellite symposia.

"We are considering, and welcome comments on, whether to limit this category to CME-accredited speaking engagements and report other speaking engagements in another category, such as compensation for services other than consulting, or additional category."

I anticipate a lot of comments on this issue will be submitted.

There are many more proposed rules in the CMS document, which runs to 121 pages! I have gotten only as far as page 34 in this summary. I hope to publish a more complete summary with comments from experts in an upcoming issue of Pharma Marketing News (subscription required).

I invite you to submit comments to this post.

Pharmaceutical Representative Magazine Closes. Blame CafePharma!

Pharmaceutical Representative Magazine Closes. Blame CafePharma!

"Pharm Rep Closes After 41 Years" is the title of parting editorial by Reid Paul, Editor in Chief of Pharmaceutical Representative magazine, which was trade publication focused on pharmaceutical sales.

"Nostalgia from my days 'carrying the bag' makes me sad to see this publication go," tweeted Mike Capaldi (@mikecapaldi), Associate Vice President at Sanofi.

"The reality is that pharmaceutical sales and marketing has changed dramatically over the past few years," said Paul. "It's more than a numerical decrease in the number of pharmaceutical sales professionals. The "traditional" sales role of the rep is rapidly evolving into something new and different that defies easy categorization. In the inaugural editorial, founding publisher Bill McKnight wrote, 'If salesmen really needed their own communication medium, then there must be enough sales managers willing to provide it through paid subscription.' While that may have been true in 1971, over the past four decades the publishing landscape has changed equally dramatically. Pharm Rep was one of the first, but now reps and execs have a broad range of options to communicate and find objective information on the industry."

Reps and execs certainly have a much broader range of communication options. As for reps, one of their favorites is CafePharma, an online discussion board for sales reps that is often maligned by pharma executives who have little time themselves for such frivolous activity! When Lilly's Deirdre Connelly described CafePharma as one of those "outlets for people who don't have the courage to speak out with their ideas," it didn't negatively affect her rise up the ranks (see here).

I'm thinking that other glossy print, paid subscription pharma trade publications will follow Pharm Rep down the worm hole of extinction.

Crestor Grapples to Compete with Lipitor: #Fail!

Crestor Grapples to Compete with Lipitor: #Fail!

I just got this email from AstraZeneca via Pharmacist eLink, which is a National Community Pharmacists Association site sponsored by the pharmaceutical industry (click on image for an enlarged view):

As readers of this blog know, my doctor once recommended I switch to Crestor from my generic pravastatin, which costs me about $7 per month via mail order (it would cost me $4 if I weren't so lazy and got it at Wall Mart). After my doctor received "speaking fees" and food from Pfizer, she recommended I switch to Lipitor because it was going off patent.

My personal experience is just one example of how Pfizer's "Save Lipitor" strategy is upsetting the statin apple cart these days.

Back to the Crestor email ad I received. First of all, this email is supposedly aimed at pharmacists who signed up to be members of the Pharmacist eLink Web site. Of course, I was able to sign up without proving that I was a pharmacist. I suggest that savvy healthcare consumers would do the same. Consequently, this ad may reach many consumers.

But AstraZeneca is trying to offer pharmacists an alternative to Pfizer's deal with PBMs that encourages pharmacists to provide "generic Lipitor" when fulfilling prescriptions for generic statins such as pravastatin. To grease the wheels of that deal, Pfizer is offering consumers a rebate that in many cases would drive the copay down to $4 per month.

But the Crestor offer doesn't sound too competitive to me: It offers a "Savings" card that promises consumers can get "CRESTOR for just $8 more than the copay of a generic statin." That is, the maximum copay would be $18 ($8 more than the average $10 copay for generics).

What consumer would be impressed by offers that cost more than what they are already used to paying? And $18 is considerably more than the $4 they would pay for generic Lipitor.

One mitigating factor, however, is that the Crestor "Savings" card will cover a 12-month supply, whereas Pfizer's savings plan expires in 6 months.

---

After I posted this, I received the following clarification from a Media Relations person at Pfizer: "I read your post today, and I think you may be confusing the Lipitor For You co-pay card with our brand loyalty programs with PBMs and health plans during the 180 exclusivity period that make the branded Lipitor available to patients at a total cost that is lower than the generic alternative. The only inaccuracy was saying the co-pay card was good for 6 months. It is actually good until the end of next year. It did appear you were blurring the lines between the two programs."

---

IMHO, the Crestor offer seems likely to fail and will have absolutely no impact on keeping Crestor competitive.

BTW, Pharmacist eLink has a lousy privacy policy and a bogus opt-out mechanism. When I click on the link to unsubscribe, what I get is merely a form to "Update your account settings" (see below), which does NOT have any "unsubscribe" option.

Meanwhile, the Pharmacist eLink privacy policy regarding opting out merely states "You may request not to be contacted by Pharmacist e-Link in connection with any new services, updates, or promotions. Requests not to be contacted by e-Link should be sent to info@pharmacistelink.com."

This is not a very user-friendly opt-out process. I will contact "info@pharmacistelink.com" and notify them of my displeasure -- as if I didn't have more important things to do!

Sales Reps in the Wild: An Interesting Way to Promote a Sales Force Effectiveness Conference

Sales Reps in the Wild: An Interesting Way to Promote a Sales Force Effectiveness Conference

I received this Twitter DM (direct message) from @eyeforpharma: "Thought you might like this. youtu.be/gCDeBAD75Pg"

There was also this @eyeforpharma tweet: "Save pharma sales from extinction. This is serious. http://youtu.be/gCDeBAD75Pg #savepharma #e4p #hcsmeu #hcsm #pharma"

Eyeforpharma (aka "E4P") is a UK company that hosts pharma industry conferences, some of which I am paid to help promote via ads on Pharma Marketing Network and Pharma Marketing Blog. I haven't been paid to write this post, however, nor has E4P asked me to write this post as a favor.

So why am I doing this?

In typical UK parlance, I just think what E4P is doing with YouTube and Twitter to promote its Sales Force Effectiveness Conference (find it on the PMN Calendar here) is "brilliant," by which I mean interesting and funny, almost "snarky" to borrow another UK phrase.

I am reviewing this here because I wonder if pharma companies can use some of the same social media techniques to promote their products or other special interests.

The YouTube video that @eyeforpharma thought I would like is titled "REVEALED: E4P Nature documentary discovers reps in the wild." It's a spoof of how pharma sales reps have been known to pursue physicians to detail them about Rx drugs. It's done in the style of David Attenborough's famous Life on Earth nature shows, portraying sales reps as wild animals seeking their prey.

The description associated with the video tells the story:

Join us as we journey to the edge of civilisation where pharmasuiticus rep can be seen in its natural habitat. In order to prevent the extinction of pharma sales entirely, CLICK HERE: http://bit.ly/prevent-extinction

Only a few dying remnants of this species now remain. The E4P team have managed to capture the last of this species and are urgently recommending immediate action in order to revitalise the remaining population.

Thank you also to our intrepid camera crew at www.stantonmedia.com for their courage in coming into such close contact with these dangerous animals.

If you would like to participate directly in the effort to save pharma sales from total extinction then please email psimms@eyeforpharma.com

Twitter: #savepharma @eyeforpharma

The video ends with the message "Your customers have evolved? Have you?" and a link to the conference site.

The last sequence in the video shows the "alpha rep" eating an iPad, which also emphasizes the "unevolved" nature of many pharma sales reps; reminiscent of the apes gaping at the obelisk in Kubrick's film 2001. Here's a screenshot:

Is it just me or doesn't this guy look like Paul Simms, the co-founder and chairman of E4P? Here's Paul as seen on the @eyeforpharma Twitter page:

A video like this must cost a pretty pence! So, it's frugal to use employees as actors. Unless, of course, the video was paid for by one of the sponsors of the conference. I don't see any sponsorship message though.

But how effective will this video be in promoting the conference and increasing registrations? It's gotten  only 172 views as of this post, but I am sure it will get many more now that I have featured it here!

One last thing. I worry about using Twitter's direct messaging (DM) service to do promotions like this. I know Paul personally and whenever he sends me a DM, I open it. I don't know how many other people Paul has DM'ed about this video or if he used an automated service to send out the same DM to ALL of the followers of @eyeforpharma. But if I start to get bombarded ("blasted") with automated DMs from people I follow on Twitter, I will not be a happy camper. To be clear, E4P has NOT sent me many DMs at all.

I use my @pharmaguy Twitter account to send out promotional messages to followers, but I do NOT send automated promotional DMs in a single "blast" to all my followers. I feel that my followers did not agree to that. I do, however, send out one automated DM to each new follower thanking the person for following me and requesting that they fill out my follower survey (see results of that survey here).

Anyway, kudos to E4P for a fun promotion.

Lipitor For You! Actually, For Card Carrying Members Only!

Lipitor For You! Actually, For Card Carrying Members Only!

"The LIPITOR FOR YOU program comes with the $4 Co-Pay Card so you can save on Lipitor, the medicine that's been helping you lower your cholesterol." So says Pfizer's new direct-to-consumer (DTC) campaign (see ad from the current issue of Newsweek on the right; click to enlarge).

I suspect we'll also be seeing these ads on TV soon. The ad, which features a nice family day at the beach, will put most people in the U.S. in a good mood when the ads run starting in January 2012, just prior to beach season!

The question is, will Pfizer spend as much on Lipitor DTC advertising as it has done in the months prior to Lipitor's loss of patent protection?

I have already noted in a previous post that Lipitor was the #1 most-advertised Rx drug in 2010, a year in which Pfizer spent a whopping $272 million on DTC Lipitor ads (see "Double Dip in DTC Spending Plus 33% Drop in Internet Display Ad Spending!"). This number refers only to "measured media" ad spending and does not include search engine online advertising (but does include, I believe, online display advertising).

But, even Pfizer admits Lipitor revenue will dramatically decrease and it only has 180 days before the real competition starts. Therefore, it must do a whole LOT of DTC advertising in the next 90 days to reap the benefits. Still, I doubt it will spend anywhere near $272 million. My guess would be half of that.

What do you think?

How much will Pfizer spend on Lipitor DTC measured media advertising in 2012?
	More than $200 million
	Between $100 and $200 million
	Less than $100 million
	I have no friggin' idea!

December 7, 2011: A Date Which Will Live in Infamy for Women's Health!

December 7, 2011: A Date Which Will Live in Infamy for Women's Health!

"If I close my eyes...I might think I was in the Bush era,” said Michelle Goldberg (@michelleinbklyn), Senior writer for Newsweek/The Daily Beast, and author of Kingdom Coming and The Means of Reproduction. Her remark -- made via Twitter, of course -- was in reference to "Obama's terrible decision to override the FDA on Plan B."

She expressed my feelings precisely!

By now you've all probably heard the news as reported in the NY Times (here): "For the first time ever, the Health and Human Services secretary publicly overruled the Food and Drug Administration, refusing Wednesday to allow emergency contraceptives to be sold over the counter, including to young teenagers. The decision avoided what could have been a bruising political battle over parental control and contraception during a presidential election season."

The action was taken by U.S. Department of Health and Human Services Secretary Kathleen Sebelius in a letter addressed to FDA Commissioner Margaret Hamburg, M.D. Find that letter plus statements by both Sebelius and Hamburg here, where you can also vote on who you think is right.

Sebelius blocked the FDA from allowing the contraceptive pill, called Plan B One-Step, to be made available without a prescription (over-the-counter) to women and girls 16 and younger who now need a prescription to get Plan B. "If taken soon after unprotected sex, the pill halves the chances of a pregnancy," according to the NY Times (op cit).

Who's right? Hambug or Sebelius? Vote here.

Be Aware of What's Behind a Pharma Mobile App: Disclaimers Only Tell Part of the Story

Be Aware of What's Behind a Pharma Mobile App: Disclaimers Only Tell Part of the Story

Some time ago, I pointed out that certain mobile apps developed by pharmaceutical companies for use by physicians lack adequate disclaimers. Specifically, I was concerned about the software used in these apps that perform calculations to generate data to aid in medical diagnoses. A Psoriasis/PASI app by Janssen Pharmaceutica is an example (see "FDA Promises Still More Guidance! This Time It's Mobile. Janssen's Psoriasis iPhone App May Need It"). I pointed out that this app does NOT include any information about the clinical validity of the PASI calculator nor does it warn the user not to depend on the accuracy of the data.

Today, I found out about AFib Educator 2.0 developed by Sanofi-Aventis (I seemed to have missed 1.0!). The app is intended to be an "interactive way for healthcare providers to illustrate atrial fibrillation and its pharmacologic management for patients and families" (see review on iMedicalApps blog). The "pharmacologic management" is not what you may think; that is, there is no mention of any AFib drug either by trade name or generic name. The app only mentions that "there are treatments available."

Let's look at the disclaimers for these two apps (click the image for an enlarged view):

On the left is the disclaimer for Sanofi's AFib Educator 2.0 and on the right is the disclaimer for Janssen's PAS calculator (updated since I last reviewed the app).

Both disclaimers mention that the app is "not a substitute for medical advice/professional medical care". But only the AFib disclaimer mentions that "Persons using the data within for medical purposes should not rely solely on the accuracy of the data herein." It also mentions that data might be updated periodically -- meaning, I suppose, corrections or more accurate data.

Why doesn't Janssen's Psoriasis/PASI app, which is MUCH more data driven (it calculates a PASI score!), include a similar warning? Obviously, I think it should include that warning.

But more importantly, Janssen's app should include information about the source of the equation it uses to calculate PASI. As I pointed out previously (op cit), there is some difference of medical opinion regarding how PASI should be calculated and which formula should be used by healthcare professionals.

Obviously, ANY healthcare professional can download and use the PASI app. You don't have to be a dermatologist who may be more familiar with PASI calculations than is a general practitioner. In fact, you don't have to be a physician at all! That's fine, but the audience should be made more aware of what's operating "behind" the app to generate the PASI scores.

Be Aware of What's Behind the App
What's going on "behind the app" is a hot topic these days. Recently, major news outlets have reported that there is software running in the background on virtually all smart mobile devices that record every keystroke, supposedly merely to "monitor performance" (see "Is Your Smartphone Tracking Your Keystrokes, Texts and Location?" and the YouTube Video embedded at the end of this post).

It's interesting that part of Janssen's NEW disclaimer HINTS that data are being collected when people use its Psoriasis/PASI app (see screen shot below).

Janssen claims that it is monitoring clicks for performance purposes. However, since it is possible to collect and record ALL keystrokes, there is the possibility that data other than icon clicks are being collected by Janssen. I'll have to see if Trevor Eckhart -- who made the video below -- will take a look at exactly what data the Janssen apps records.

Gov't SoMo Media Aimed at Teen Smokers: We're Not Telling You What to Do

Gov't SoMo Media Aimed at Teen Smokers: We're Not Telling You What to Do

I just learned that the National Cancer Institute (NCI) has launched a Mobile phone app ("SmokefreeTXT") and a social media campaign designed to help teens quit smoking (see "Nci Launches Smoking Cessation Support For Teens").

SmokefreeTXT is a free text message cessation service that provides 24/7 encouragement, advice, and tips to teens trying to quit smoking.

"Once they sign up, teens receive text messages timed according to their selected quit date. Following their quit date, they will continue receiving texts for up to six weeks -- a critical piece of the SmokefreeTXT service, as research shows that cessation support continues to be important beyond the first few weeks of quitting. Teens can sign up online at or text QUIT to iQUIT (47848)."

An image of an iPhone with a quit smoking text message is shown on the left (click on it for an enlarged view).

I hope it's more personalized, so instead of saying "Teen: SUCKY" it says something like "John feels SUCKY today." Maybe with a little sad face emoticon :-( afterward.

I like the encouraging message, however. "Do something positive. Get your zumba on, shoot some hoops, or crank up your iPod."

There's also a website (here),  @SmokefreeTeen Twitter account, and a FaceBook page (here). I call this type of campaign "SoMo" because it combines social media with a mobile app. It would have been nice to integrate social media INTO the mobile app -- eg, have quit smoking buddies and see how THEY are feeling today right on your iPhone (or iPad).

The About SfT page notes that "We're NOT ging to tell you what to do." As if anyone can tell teenagers what to do!

One of the things I like about social media is how easy it is to see how "successful" campaigns like these will be. We can always look at how many followers a Twitter account has and how many "Likes" a Facebook page gets. It's always possible, however, to game the system and artificially inflate the number of your Twitter followers or Facebook likes. But that's another story (see "How Did Pfizer Get So Many Twitter Followers?").

Is the Pharma Industry Responsible for FDA's Delay in Issuing Social Media Guidelines?

Is the Pharma Industry Responsible for FDA's Delay in Issuing Social Media Guidelines?

I just read an interesting MM&M piece about how measures to curb the deficit might impact the pharmaceutical industry (see "Pharma Marketing Outlook 2012: Detailing D.C."). One small comment caught my attention: "A first draft of what is likely to be one of several not-crystal-clear guidances on social media and Internet communications has been circulating at FDA for most of the year, held up over legal worries." [my emphasis]

Oddly, no details were offered regarding the nature of the "legal worries." As the author of the MM&M piece probably knows, I wrote about this back in July when I suggested that a "Citizen Petition Filed by Pharma Likely to Delay Indefinitely the Issuance of FDA Social Media Guidance" (here). The petition asks for "comprehensive, clear and binding regulations" as opposed to "guidelines," which are non-binding (ie, can easily be changed by the FDA).

Before granting a petition, FDA staffers evaluate it, "a process that may take several weeks to more than a year, depending on the issue's complexity," according to the FDA.

Why is this such a big deal? I have pointed out that if the petitioners -- Allergan, Eli Lilly, Johnson & Johnson, Novartis, Pfizer, Novo, and Sanofi-Aventis -- are not satisfied with how the FDA responds to the petition, they are likely to "take the matter to court" ( further hamstringing the FDA efforts to issue social media guidance. The number one pharma company and one of the petitioners is already on record opposing any social media guidance on first amendment grounds (see "Pfizer Asks for New FDA Regulations, Not Guidance, for Social Media").

In particular, the petitioners are looking for more guidance in four key areas: scientific exchange, sharing information with formulary committees and payers, providing independent third-party clinical practice guidelines, and responding to unsolicited requests for information. It seems that the FDA changed its social media agenda -- thus further delaying issuance of guidance -- to satisfy these specific needs (see "FDA Drops Social Media from Its 2011 Guidance Agenda").

You can find and read the petition here.

Another, related, "legal worry" that could be holding up FDA's issuance of social media guidance is a "friends of the court" brief to the court hearing the appeal of the Caronia off-label promotion case. This petition was filed by some of the same pharmaceutical companies mentioned above (see "Pharma Turns Up the Heat on Off-Label 'Free Speech' Chilled by FDA - Implications for Social Media Marketing"). The companies -- who call themselves the Medical Information Working Group (MIWG) -- contend that FDA's regulations "lack coherence and clarity." MIWG is talking about regulations regarding off-label information disseminated by regulated companies such as themselves.

This push for an end to FDA's off-label marketing ban is the latest industry action that puts the FDA in a very weakened position viz-a-viz issuing any marketing guidance (and certainly NOT social media guidance) for the foreseeable future. The industry hopes the court case in question -- the Caronia off-label promotion case -- will end up in the Supreme Court. In the meantime, FDA is probably thinking "let's wait and see what happens before we issue any new guidance that 'lacks coherence and clarity'."

Are Pharma Sales Reps Service Employees?

Are Pharma Sales Reps Service Employees?

The Supreme Court agreed to decide whether drug companies have to pay their sales representatives for working overtime hours, "a question that could have considerable financial impact on the industry," according to the Wall Street Journal (see "Supreme Court to Decide if Pharma Reps Are Exempt from Receiving Overtime Pay"). The question (see here) before the court in case "CHRISTOPHER V. SMITHKLINE BEECHAM CORP" is:

The outside sales exemption of the Fair Labor Standards Act exempts from the overtime requirements of the Act "any employee employed ... in the capacity of outside salesman (as such terms are defined and delimited from time to time by regulations of the Secretary ...)." 29 U.S.C. § 213(a)(1). The Secretary of Labor has implemented various regulations that "define and delimit" the outside sales exemption and, filing as amici in this and other related matters, has interpreted these regulations to find the exemption inapplicable to pharmaceutical sales representatives. A split exists between the Second and Ninth Circuits concerning whether this interpretation is owed deference and whether the outside sales exemption of the Fair Labor Standards Act applies to pharmaceutical sales representatives.
The questions presented are: 

1. Whether deference is owed to the Secretary's interpretation of the Fair Labor Standards Act's outside sales exemption and related regulations; and  
 
2. Whether the Fair Labor Standards Act's outside sales exemption applies to pharmaceutical sales representatives.

If the Supreme Court rules that pharma sales reps are NOT exempt as per Q#2, some sales reps worry that they will become "service" employees. "This will be a similar model to UPS / Fed Ex etc. Log in.............track activity..........gps............clock out at 5:00 pm." (see this CafePharma thread in the GSK discussion board).

This is interesting considering that the pharmaceutical industry is now moving away from the sales force being the primary channel of promotion focused on a narrow stakeholder audience to that of "a multi-faceted influence model where it has to really maximize its return on investment,” according to Mark Sales, Head of Global Brand and Stakeholder Management at Kantar Health (see "The Changing Pharma Commercial Model in 2010 and Beyond"; a PMN article sponsored by Kantar Health). The new sales model drivers are all about becoming more customer-centric and service model-focused. So, a NO ruling by the Supreme Court in this case would be a good thing for the pharmaceutical industry, aside from the billions in additional expenses?

Reps also worry that their companies would cut back on the number of sales reps and overtime hours to forestall the added expenses going forward. "The problem is that if overtime has to be paid out it will lead to more cuts," said an anonymous CafePharma poster. "Lets face it, the impact of reps has been going down for quite a while."

What do pharma sales reps do in "overtime" (after 5 PM) anyway? It may be "role-playing": "Would the role playing to India at 9:00pm count as overtime?," asks another anonymous CafePharma poster. "Get ready for bye bye role plays after 5pm," said another.

Some reps do not think this is an issue at all: "Since most reps really only work a couple hours a day, this really looks like a non-issue." To which this response was made:

"Actually it's a huge issue! Other big pharma companies have had to pay and pay big! This could cost GSK hundreds of millions. As to your comment about a couple of hours, please stop with that nonsense. I avg about 9 hrs per day. It's not back breaking work (that's why I went to college) but it is work. Inventory at the storage facility, lifting boxes, conference calls, emails, coordinating lunches/dinners, knowing and understanding the complex molecules and how they interact invivo/invitro, analytics, ability to utilize Microfoft word/excel, intrapersonal skillls, the list goes on an on...oh but you say reps only work 2 hours. When are reps supposed to answer email, voicemail, build a business plan? On their office day? Ohhhh that's right, there is no office day. So when does all this work get done? According to you we only work 2 hrs a day. C'mon dude! Look, I'm not saying the law suit is a good thing, but the pharma companies had their cake and got fat eating it."

Deconstructing Pitts' Guiding Principles for Pharma Social Media

Deconstructing Pitts' Guiding Principles for Pharma Social Media

Peter Pitts over at DrugWonks Blog has put together 11 "principles that must serve as the basic substrate of regulated social media participation" (see here). Pitts offered these principles because he is urging the pharma industry to participate in social media and not wait for FDA guidelines "not because of its potency as a marketing vehicle – but because it’s the right thing to do." Let's take a closer look at "Pitts' Principles."

Principle  1. "We engage in social media to help improve the lives of patients and advance the public health of our nation."

"improve" is the key word here. We all have different definitions of what it means to "improve  the lives of patients and advance the public health of our nation." I, for example, think it is very important to make sure all Americans have affordable healthcare insurance and support efforts to close the gap in Medicare Part D coverage (ie, the "doughnut hole"). The drug industry may not agree with me 100% on this. Lilly, for example, hosted a Twitter "chat" that tried to convince people that Medicase isn't broken, so don't fix it, but I asked "Was Lilly's #mmeds Twitter Chat a Discussion or a Press Conference?" (read this post). Also see "More Pharma Twitter Chats: Medicare is Topic."

Even if we agree on how to improve patient lives, it has not been proven that social media actually can help in this effort. There are plenty of other ways that the drug industry can -- and does -- do things to help improve patient lives. Perhaps social media can help in those efforts (see, for example, "Boehringer Ingelheim and Ashoka Make More Health via Social Media."

Principle 2. "We will thoughtfully engage in social media while remaining in compliance with both the letter and the spirit of FDA regulations."

The word "thoughtfully" requires definition, IMHO. There have been many occasions when pharma companies have seemed to put little thought into their social media activities (see, for example, "BI Masters the Art of WOM through Its 'Parrots,' er, Spokespersons"). 

Seriously, however, "thoughtful" implies best intentions as in showing consideration for the needs and sensibilities of other people (eg, "how thoughtful of you!"). Perhaps Pfizer lacked "thoughfulness" when it promoted on FaceBook a Chapstick ad that angered quite a few women (see "Pfizer's Facebook Fiasco: Chapstick Slapstick Ad Uses Woman's Ass as a Prop").

Principle 3. "Our social media engagements will have both strong public health themes and appropriate marketing communications."

IMHO, "appropriate marketing communications" is the big elephant in the room that cannot be dealt with UNTIL the FDA says what is and what is not "appropriate." This requires more than being compliant with the "spirit of FDA regulations" as noted in Principle 2. It requires being compliant with the "letter" of FDA regulations. Of course, without the "letter" being written by the FDA, there can be no compliance with it.

Principle 4. "All social media messages and partnerships must be accurate, appropriate and transparent."

Pitts said "One principle that runs as a red thread throughout all of these 11 principles is transparency. Real, honest transparency – not the usual translucency that 'in compliance' often brings." I can't agree more. But this is where the drug industry will have problems. I can cite many instances of lack of "transparency" in pharma's social media activities that I have blogged about. For example, during a Lilly-hosted Twitter chat about Medicare, I suspect an employee or agent hired by Lilly posed as an ordinary citizen (@ellsbelles3) who posted "I keep hearing that Medicare Part D is working and not to change it. what does that mean?" This sounded suspiciously like a setup from a phony ordinary citizen similar to "Joe the Plumber" (see "Was Lilly's #mmeds Twitter Chat a Discussion or a Press Conference?"). Although I suspect that Lilly was not being transparent about this, I cannot prove it. That's the problem with transparency in social media -- nobody can prove you are not a "real patient" and it's very easy for unscrupulous players to manipulate the game (ie, conversation).

Principle 5. "We believe that social media presents multiple opportunities to learn more about how our products impact the lives of patients."

Sounds good to me. I hope that pharma is actually listening and learning. It would be interesting to know exactly what the industry is learning about its products from monitoring social media. However, very few companies will even admit they are monitoring social media for fear that FDA will learn that they are not reporting adverse events they hear about (see Principle 7).

Principle  6. "We believe that social media engagement allows us to correct errors and misperceptions about both our company and our products."

"correct errors and misperceptions" is really a slippery slope. Who defines what is "correct" and "not correct"? There are many scientific studies and clinical trials whose results are challenged by the drug industry but that are accepted as correct by other experts. All sides of a debate involving scientific evidence should be discussed with the (transparent) participation of the industry. But if the goal of the drug industry is to "correct" other points of view, then the industry will not be engaging in discussion but trying to manipulate it. Also, keep in mind that the industry itself has often been caught make false statements about its own products -- hence all the warning letters from FDA!

A little pedantic aside: "misperceptions" is a curious word choice. Since Pitts is known to choose his words carefully, the distinction deserves some analysis in the present context of "misperceptions" of drug products by the general public.

According to Grammarist: "To perceive is to become aware of something directly through the senses. To conceive is to form something in the mind or to develop an understanding. So to perceive is merely to see something, and to conceive is deeper. But perception often involves passive evaluation, and this is where the line between the verbs perceive and conceive becomes blurred. Think of perceptions as relatively shallow interpretations, and conceptions as more creative interpretations involving substantial thought or imagination. Think of a misperception as a mistaken impression... and a misconception is a mistake of imagination or interpretation." A simpler distinction: Misperception, means to not understand, misunderstand; Misconception means a mistaken thought.

It's possible that patients, for example, might believe that a muscle ache after being prescribed a statin for high cholesterol is a side effect of the drug. This could be a "misperception" (not a a true pain) or a "misconception" (a real pain but not caused by the drug). Another example: some patients may believe the risks of a drug outweigh the benefits and then decide not to adhere to the treatment regimen prescribed by their doctors. Is this a "misconception" or a "misperception?" Of course, it may be neither: the risks may actually outweigh the benefits!

Anyway, perhaps a better word to use in this context would be "misunderstandings."

Principle 7. "We believe in using social media to discover adverse drug experiences, which will then be addressed off-line."

I like this, but would like to see more real-world examples. I recall only one example of a pharma company that has publicly embraced discovering AEs via social medias: ie, UCB, which partnered with PatientsLikeMe  to create an online, open epilepsy community that includes a pharmacovigilance program to monitor the site for adverse events and report directly to the FDA adverse events associated with UCB products (see "Finally, a Drug Company Embraces Social Media, AEs Included!"). I haven't heard much about this lately -- did UCB find many adverse events and what else did they learn (ie, re Principle 5)? I've seen several studies by agencies that work for the pharmaceutical industry that suggest very few reportable AEs are found on social media sites. PatientsLikeMe, however, reported that 7% of 500 randomly selected posts from the 364,000 posts contributed by patients within the PatientsLikeMe Forum during 2009 incorporated all four elements required for reporting an adverse event (see "PatientsLikeMe Reports High Rate of Adverse Event Reporting Among Its Members"). Also see: "The British Pharmaceutical Industry Issues Social Media Guidance for Adverse Event Reporting."

Principle 8. "We will strive to interact in a timely manner, appropriate to the general expectations of social media."

I expect there's a difference in opinion of what is meant by "timely." As has been demonstrated many times, pharma can get into trouble when it does not respond in a timely fashion to social media crises as was the case with Sanofi's response to a disgruntled patient (see "Disgruntled Patient Shuts Down sanofi-aventis Facebook Page"). The ultimate decision of whether a response is "timely" or not is up to the customer (ie, patient, physician, or payor). Whether "striving" is adequate or if "succeeding" is better, remains to be seen.

Principle  9. "We believe that social media must be regularly monitored and our programs measured in real time to gauge effectiveness."

See my comments under Principle 5. The industry also is struggling with how to "measure" social media campaigns. There is also a question whether or not social media should even be campaign-oriented, which implies a beginning and an end.  We've already seen pharma companies shut down Facebook pages and abandoning their social media audiences (see "Pharma Facebook Pages Being Phased Out: A Good Run While It Lasted! Did Facebook Kill the Beast?"). Companies are blaming new Facebook rules for the shut-downs, but I think "campaignitis" has hit -- new marketers come on board and want to run their own "campaigns" or the "campaigns" were not as successful as expected. Which leads me to ask, How do you measure social media success?

Principle 10. "We respect but are not responsible for user-generated content that resides on sites we do not control."

This should not be a principle. It's just common sense. Duh! But wait! The word "control" needs to be defined. Comments to FDA by several drug companies addressed this.

Principle 11. "We believe the path to engagement is through useful and thoughtful content and commentary."

I've already commented on "thoughtful" (see Principle 2). "engagement" is a key word here. What do pharma marketers really think of when they think of "engagement?" Is it the same as what you or I think of? If pharna social media programs are controlled by marketers or corporate communications people, it's difficult for me to think the goal is not just "engage" but also to "convince." That was my criticism of the Lilly chat regarding Medicare (see "Was Lilly's #mmeds Twitter Chat a Discussion or a Press Conference?"). Also see "Will Patients Find Value in Discussions with Pharma Marketers on Social Media Sites?" 

A book can be written about this stuff and I suspect someone out there is already finished with the first draft. I thank Peter Pitts for drawing up these 11 principles around which we can organize an ongoing discussion. I invite your comments.