Pharmaceutical sales reps are now more likely to engage with physicians online and through other forms of nonpersonal promotion than in-person visits with doctors at their offices, according to ZS Associates.

This is because the number of what the consulting firm calls “rep-accessible physicians” continued to decline in 2016. Only 44% of physicians surveyed by ZS said they will meet with sales reps. This is down slightly from 46% in 2015 — and significantly from 80% in 2008.

Fifty-three percent of marketing to physicians is now done through nonpersonal promotion, which can include emails, mobile alerts, direct mail, and speakers programs. The remaining 47% of marketing takes place during in-person meetings between sales reps and physicians.

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“Physician reach is getting harder and harder, so we see more nonpersonal promotion,” said Malcolm Sturgis, associate principal at ZS. “But pharma’s old way of marketing [that is] heavily dependent on physician detailing is just less productive.”

More doctors are now employed by hospital systems and independent delivery networks, which are cracking down on pharmaceutical influence on prescribing, in part to stem conflicts of interest but also to address rising drug costs. Physicians may also have some fatigue when it comes to dealing with the industry — drugmakers reportedly try to contact certain doctors once every hour, through varied forms of promotion.

Still, there are several reasons why physicians are willing to engage with sales reps. Doctors are interested in learning more about novel drugs, regardless of the therapeutic category or their individual specialties. Categories and diseases that make the cut include cardiology, gastroenterology, and hepatitis C. “These are things that are changing the treatment paradigm,” Sturgis said.

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Additionally, as drugmakers continue to lose direct access to physicians, there are other ways to market to clinical staff. Manufacturers can instead approach nurse practitioners and physician assistants; 53% of NPs and physician assistants will meet with sales reps.

They might also coordinate messaging across all brands owned by one pharmaceutical company, rather than send out a flurry promotions for a number of brands to one physician. Physicians often complain about the number of times that companies contact them. Some doctors spend as much as 84 hours per year interacting with drugmakers through digital or nonpersonal channels, according to ZS.

“These tactics can work and can be effective when executed well,” Sturgis said.