Paywalls threaten healthcare professional engagement on social media

The recent announcement that Elon Musk is considering introducing a paywall to X caused much discussion over the future of the platform. Ben Hargreaves finds that HCPs and patients have spent years building up communities centred on improving health and sharing knowledge, but analysis shows this would be in danger of being disrupted by a paywall.

To say that Elon Musk’s takeover of X (formerly Twitter) has been eventful would be an understatement. In the lead up to and after the completion of the $44 billion deal, the social media platform has rarely been out of the headlines. One of Musk’s aims has been to make the platform profitable, as he admitted in July 2023 that X had lost almost half of its advertising revenue and had a negative cash flow.

This is one of the reasons behind Musk’s mooted plan to introduce a paywall to the service. Paywalls have become a regular feature for online publications, in efforts to generate revenue for content that had traditionally been provided freely online. However, for a social media platform, paywalls are not typical – as the dominant strategy has been to boost user numbers and to generate revenue through advertising, rather than directly through users.

Explaining the thought-process behind it, Musk noted that one of the purposes of a potential paywall would be to undermine the presence of bots on the platform. By charging a small monthly fee, reportedly a ‘few dollars’, bots could be squeezed out from the platform on a cost basis, and also due to the need for individual payment methods for each account.

Though potentially effective at finding a solution for bot accounts, the suggestion that the platform could go behind a paywall could directly harm the numbers of users, depending on how many would be prepared to pay for the service. X has become particularly popular among healthcare professionals (HCPs) as a means of communicating with other professionals and to patients within specific treatment areas. By forcing those individuals to pay, there is the chance that these support networks would fail.

Underwhelming support

The response from the HCPs themselves emerged immediately, via X. Creation.co, a specialist digital insights consultancy, is able to track the conversations happening on the platform, and found that less than 2% of HCPs discussing the potential paywall expressed support of the idea.

Further, posts by HCPs showed that in the immediate aftermath of the comments, the number of registrations to a rival social media platform, BlueSky, had ‘dramatically increased’. According to Creation, the general sentiment expressed by HCPs was one of resentment towards potentially losing their network of medical professionals, built up over the years of using the platform.

When asked directly about the likely impact on HCPs with the imposition of a paywall, Jamie Doggett, associate director of insight at Creation, stated: “It's clear from Creation's studies of the digital behaviours of HCPs that X provides a unique tool for peer collaboration, and it's still the biggest network of millions of HCPs tracked by Creation Pinpoint. We have, however, tracked HCPs saying that they refuse to pay for X. It does seem clear that charging for X will drive away some, if not all, HCPs from the platform.”

Looking for alternatives

Doggett also outlined that some HCPs are already adapting by adopting new channels for engagement, by expanding the number of platforms on which they are operating. In a specific example, it was noted that Dr Kevin Fernando, a UK-based general practitioner and one Creation’s marked top-50 most influential digital opinion leaders in diabetes, had launched his own TikTok and YouTube channels shortly after the announcement.

With conversations taking place looking at exiting X, the company also performed analysis of the common alternative platforms for those who were unhappy with plans for the paywall to be introduced. The results showed that the most popular alternatives were BlueSky, followed by Meta’s Threads, and its Facebook platform, and, lastly, Mastodon. The numbers involved showed no clear frontrunner between the competing platforms, indicating a short-term mass migration is less likely, Creation stated.

Despite the controversy over the paywall, Doggett pointed out that discussion of Musk’s ownership of X has dramatically fallen since November and December 2022. This was primarily due to the initial surge in speculation regarding the overall direction of the platform, as Musk’s prioritised ‘free speech’ and controls were lifted over misinformation in certain areas, including COVID-19.

A necessary outlet

Creation is able to draw upon such information and data points through the use of its Pinpoint system, which is a proprietary AI engine utilising a global HCP social media database. Doggett told pharmaphorum that the AI tool has analysed more than two billion HCP posts on X. As such, when asked about how HCP engagement with the platform has changed with Musk in charge, Doggett was able to confirm that there has been no marked decrease in activity, though the results vary between differing therapy areas.

The platform’s analysis allows Creation to identify that, in a comparison between the first nine months of 2022 and the first nine months of 2023, online conversation within a ‘certain metabolic disease area’ grew by an average of 184 posts per day, including more than 5,000 additional HCPs in the conversation. By contrast, within the same date range, a sub-set within oncology saw numbers decrease by an average of three posts per day.

Previously, there had been concerns that the drop in moderation on the platform would lead to a lack of trust and therefore a drop in engagement, as HCPs chose not to recommend X communities to patients. According to the statistics, this has not happened to any significant degree. The conclusion is that patients and HCPs see a strong value in such a platform, regardless of controversies over ownership and direction, in the short-term.

“What is clear is that HCPs coming together on social media to discuss concerns, treatments, innovation, etc., is continuing to grow. It is not something that will be impacted by the behaviours of one media platform – HCP networks and communities on social media is the new normal for global healthcare. The importance for those wanting to harness this understanding is making sure they have the right tools in place to hear and understand all of the conversations, wherever they may be,” Doggett concluded.