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New Year Resolution: Stand Up to Healthcare Marketing Hypocrisy!

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Well-intentioned measures can go very wrong. Time to call out the disturbing hypocrisy directed at healthcare marketers.

On the last day of the passing year the New York Times published a front-page feature on PhRMA's recent policy to discourage giving swag to doctors: "No Mug? Drug Makers Cut Out Goodies for Doctors".

While many people welcomed this policy I was quite appalled by how easily did PhRMA cave to interest-group pressure, instead of taking a principled stand for healthcare communications. I understand PhRMA has many irons on fire and has to pick its battles. Unfortunately, their decision lends credence to some really rotten arguments used by the supporters of the ban. Someone has to speak up!

So where is the hypocrisy in healthcare marketing restrictions?

The idea that healthcare marketing must be severely restricted, with banning gifts to physicians being just one example, is based on several premises. These premises keep getting cited by the proponents in various forms. Here is my summary of "Top 3" myths and explanation of what is wrong with that line of thinking:

Myth #1: Paid marketing always causes improper influence

I am not going to argue that the goal of any marketing campaign (swag, TV spots, Internet media, etc) is to influence the recipient of the message. The question to ask is what constitutes proper vs. improper influence and why. Of course truly misleading and deceptive practices are indeed a problem. But if a pen or a cup is there to simply *remind* the doctor about that particular brand available, what is wrong with this if the prescribing decision is still made on merits of patient's case? Drug companies make for convenient scapegoats and are far too easy to attack. What we have not seen are *any* credible studies directly linking swag to unsafe prescriptions and demonstrating which marketing tactics are at fault.

Myth #2: Unpaid communication is free of improper influences

The real scandal is that media obsession with little things like cups and pens distracts attention from the real problem: influences are everywhere. Everyone is always influencing everyone else. Physicians interacting with physicians. Patients talking among themselves. Patients-to-physicians and vice versa. Medical journals. Pharma sponsored CMEs. Grants to medical schools. Academic careers staked on this or that concept. Everyone has an agenda and there are far more powerful motivators to do something wrong, that little trinkets. Social and professional pressures could be way stronger than monetary and shifting blame to marketing is an easy cop-out to avoid confronting the real influences.

Myth #3: Marketing is unnecessary and never mixes with health

Newsflash - we are all marketers! When a medical researcher is trying to get a paper published, she is marketing to the journal. When a physician is trying to get patients to comply with his recommended treatment, he is marketing his reputation and education to the patient. When a patient is trying to get a prescription, based on his feedback from a support group, she is marketing her view of her condition to the doctor. We try to influence people around us daily and there is nothing wrong with that. The only difference with *paid* marketing is using money to expand the reach and effectiveness of the message. There is nothing wrong with that as long as the message itself is not improper or deceptive.

The efforts to banish marketing from healthcare remind me of the continuous crusades to get money out of politics. This is a hypocritical game played for the sake of appearances, producing few tangible results and always causing the money and influence to find some other channel to flow through, just like the laws that "prevent members of congress to have lunch with lobbyists sitting down, but they can still have lunch standing up". I find much more honest and truthful the views of California's legendary Assembly Speaker, Jesse Unruh, famous for some colorful quotes about the politics and lobbying:

On money: Money is the mother's milk of politics

On lobbyists: If you can't drink their whiskey, take their money, sleep with their women and still vote against them in the morning, you don't belong in politics

The last quote could easily apply to physicians and drug companies. Physicians who protest the bans on swag rightfully point out that suggestions that they cannot resist influence of a $1 pen imply complete lack of backbone and medical judgement. On the other hand, consider how the *same* kind of influence can flow through "social" or "commercial" channels with dramatically different perception:


About time we confront the hypocrisy head-on. To support the cause, I created a Facebook page and encourage you to join as a fan.

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Comments (12)

Submitted by David Moskowitz MD FACP (not verified) on Wed, 01/07/2009 - 11:46am.

If you really want to discuss hypocrisy in healthcare, the following suggests the problem goes much deeper than whether doctors get their swag from the few remaining pharmaceutical companies in business. The entire healthcare industry no longer wants to cure disease, all the while insisting that more money be spent on irrelevant research.

A MODERN-DAY TUSKEGEE

AND A GLIMPSE
OF WHAT’S REALLY WRONG WITH U.S. HEALTHCARE,
FROM AN INSIDER

The crime of the Tuskegee Syphilis Experiment isn’t so much that
it was a stupid experiment—medicine improves only through clever experiments,
and stupidity is seldom criminal. What made Tuskegee so shameful
was that a cure for syphilis had finally been discovered, but news of the cure
was deliberately kept from the patients who needed it the most, those with
tertiary stage syphilis, just so investigators could see how they died.

For the past 6 years, the world has been hurt hundreds of times
worse than by Tuskegee. Like the Tuskegee
syphilitics, the patients affected aren’t even aware of the injustice. As in Tuskegee, patients
are paying with their lives. Unlike Tuskegee, scientific
curiosity isn’t the motivation, just greed.

In 2002, I published a method to reverse diabetic and hypertensive
kidney failure (1). It works for whites, blacks, and Hispanics, i.e. the entire
world. Hispanics are a complex ethnic mixture of Caucasian, African, and
Amerindian. The kidney machine claims blacks five times, and Hispanics and
Native Americans three-fold, more than whites.

There’s also an epidemic of diabetes on Native American
reservations. Until recently, there was no diabetes at all. But in the last
generation, 50% of Native Americans have become diabetic. The explanation is
that Native Americans’ “thrifty genotype,” which permitted survival for
thousands of starving generations, produces obesity and diabetes when mixed
with a rich Western diet and physical inactivity.

As a result, dialysis units are being built on every Indian
reservation in the country. The National Institutes of Health (NIH) has been
studying diabetes in the Pima Indians for 30 years, with nothing useful to show
for it.

So when I published my paper in 2002, I expected it to be
front-page news in the New York Times. But the media refused to take my
word for it, asking me to get an endorsement from an authority in the renal
community.

I suppose that's fair enough, but somewhat depressing: even Larry
Altman MD, the medical reporter for the New York Times, confessed to me that he
couldn't evaluate a scientific paper on its own merits. Science majors learn
how to do this their freshman year in college.

Since 2002, not a single medical authority has come forward to
endorse my study, even though the founding Director of the US Renal Data
System, Dr Lawrence Agodoa, called my data "beautiful" in a private
conference call in early 2004. He said the rules of the NIH, his employer,
refused to let him endorse a company. (The NIDDK now says Dr Agodoa's comments
were taken out of context). That's the same response the American Diabetes
Association gave me, even though they partially funded the underlying research.
It's also what the National Kidney Foundation told me repeatedly. Apparently
this applies even if a company discovers a cure for the disease they're
collecting tax-free funds for, which seems a bit disingenuous as far as the
public is concerned.

Apparently, no non-profit wants to repeat the mistake of the March
of Dimes, which cured their raison d'etre in the 1950s, and has been a shadow
of its former self ever since.

In October, 2004, I presented my paper to the then Medical
Director of Medicare, Sean Tunis, and his senior staff, including Sandy Foote.
Medicare is the "single-payer" for dialysis and kidney
transplantation, and currently spends about $25 billion a year for end-stage
kidney disease.

Incredibly, they had no interest. Only later did it dawn on
me that they'd be eliminating 90% of their own jobs along with 90% of their
budget, which would terrify any bureaucrat.

Neither did the NIDDK (the Kidney Institute at the NIH), the AHRQ,
the American Heart Association, the American Association for Kidney Patients,
the CDC, the AMA, the National Medical Association, numerous academic
Nephrology Divisions, numerous kidney transplantation societies, the American
Society of Nephrology (ASN), the
International Society of Nephrology (ISN), the European Society of Nephrology,
individual nephrologists and transplant surgeons, multiple health insurance
companies, multiple health plans, all 50 state Medicaid offices, the American
College of Physicians, even religious leaders vocal about healthcare, et al.
(2).

Like the American Diabetes Association, the Missouri Kidney
Program, which co-funded the key research, has had no comment.

The medical director of Anthem Blue Cross/Blue Shield, whom I know
personally, and who is now medical director of Wellpoint, with over 100 million
patients, told me that my 1,000 patients weren't enough. "Come back when
you have 100,000," he said, knowing full well that it took me 9 years to
publish my paper on 1,000 patients. At that rate, he could safely wait 900 more

years.

Currently, 100,000 patients go on dialysis in the US each year.
My method could prevent 90% of whites, and 95% of African Americans and Native
Americans, from losing their kidney function. It's fair to say that, had my
paper received the notice it required, back in 2002, 90-95% of patients could
have been kept off the kidney machine at least since 2006, and perhaps earlier.
(I have to treat patients early, before they've lost half their kidney
function, i.e. while their serum creatinine is less than 2 mg/dl. Once they’re
on dialysis, it’s too late).

So conservatively speaking, 200,000 patients are currently on
dialysis whom I could have kept off, had anyone at the NIH, CDC, NKF, etc.
simply spoken to a reporter about my paper.

Once on dialysis, patients live only a handful of years. A 65 year
old man starting dialysis has a life expectancy of 2.5 years--as opposed to
decades with syphilis.

So I reckon the collective silence of the medical community,
including government as well as non-profit institutions, is at least 500 times
worse than their silence during the Tuskegee experiment: 400 Tuskegee patients
vs. 200,000 dialysis patients. And the crime continues. Each day, another
275 patients go on dialysis for the first time, and soon die, 250 of whom
GenoMed could have prevented.

Not to mention the people outside the US whose
kidneys fail.

This issue painfully illustrates what's really wrong with US
healthcare and, indeed, with hospital-based healthcare everywhere around the
globe. Its business model requires disease. Patients must get sick for revenues
to flow. A dialysis patient brings in $100,000 annually for the roughly 3 years
s/he's alive. See, for example: http://medicine.lifescienceexec.com/

Access is not the real issue; quality improvement is.
Spreading manure doesn't change what it is. Healthcare everywhere,
not just in the US, is
anti-innovative and therefore exploitative.

Single-payer advocates should realize that Medicare is already a
single-payer for dialysis. National Health Services in other
countries, e.g. Canada, Germany, Spain, France, Germany, Russia, Japan,
Singapore, etc. have had no interest in my method of preventing dialysis,
either. In other words, Medicare is just like every other Single-Payer around
the globe. Bureaucrats want to hang onto their own jobs more than anything
else.

I believe that any discussion of healthcare reform is dangerously
uninformed without taking into account this stark example of what’s really
wrong with the healthcare industry.

The fix is simple. To improve outcomes, start by reporting them.
Next, encourage competition. Keep at least two payers around. A single payer,
like any monopoly, gets complacent.

This solution is practically free: just mandate reporting of
patient outcomes for anybody getting paid with federal dollars (and that
includes most patients). Post clinical outcomes for each insurance plan, each
hospital, and each physician on the web, for all to see. How many diabetic
patients seen by Dr. X go on dialysis? How many in Dr. Y’s practice?

Then let patients vote with their feet. This would ensure
competition on outcomes, and tie economic survival of health plans and
practitioners to their patients’ survival. In one neat trick, we will have
inverted the current business model for healthcare, so that it actually
benefits patients rather than preys on them.

References

1. Moskowitz DW. From pharmacogenomics to improved patient
outcomes: angiotensin I-converting enzyme as an example. Diabetes Technol Ther.
2002;4(4):519-32. PMID: 12396747.
(For PDF file, click on paper #1 at: http://www.genomed.com/index.cfm?action=investor&drill=publications)--this
paper reports on 1,000 white and black male veterans. An additional 350
Hispanic men and women with diabetes were treated during the period 2001-2007,
and showed no progression of their normal kidney function (unpublished data).

2. Moskowitz, DW. Promoting dialysis alternative. Letter. ACP Observer,
Dec. 2006 (http://www.acponline.org/journals/news/dec06/letters.htm)

Submitted by hippocrates on Wed, 01/07/2009 - 3:04pm.

David, thanks for sharing your story. My original post  has been focused on hypocrisy around healthcare marketing, but I agree the problem with hypocrisy in healthcare is much broader.

Submitted by hgstern on Thu, 01/08/2009 - 7:08pm.

which is that the cost of all that "swag" increases the cost of health care. No one knows how much, of course, but it's an easily deleted expense that does nothing to add to the efficacy of either the medication itself or the system as a whole.

I also think you've introduced a straw man in your first myth ("Paid marketing always causes improper influence"). AFAIK, no one is claiming that the swag "always" causes improper or less efficient prescription behavior. Rather, it's the "appearance" that it does that causes a problem: if I see a bunch of mugs on the doc's desk, all from Pfizer (or whomever), how do I know that he's prescribing their med because it's the best one possible, rather than because he relishes his little collection?

I believe, BTW, that it isn't only health care that suffers from this problem: I decided a long time ago to never participate in any carrier's sales contests. Yes, I gave up the potential of a free cruise or iPod, but I also know that whatever policy I sell is the right one (in my professional judgement) and is free of any undue influence. Again, I may well have suggested that policy anyway, freebie or no, but this way I know -- and more importantly, my client can be sure - that there's no extra incentive involved.

Are you suggesting that an insurance agent is more ethical than a physician?

(You don't have to answer that)

Submitted by hippocrates on Fri, 01/09/2009 - 2:25am.

Hank,

The point about the cost of swag contributing to the cost of care is a reasonable one. However there could be several counter-arguments. One is, physicians still need pens and mugs and instead of letting pharma carry the cost would have to increase their office budget, still increasing cost of care. Another one, consider all marketing costs the price of information distribution. If pharma-subsidized information channels are taken away, doctors will have to take on added responsibility and cost of keeping up to date. The cost does not really go away, it just gets shifted around... We just cannot correctly put the $$$ value on the information efficiency.

Second point about your refusal to participate in carrier sales contests, I believe this shows how things should work in the free market environment. By announcing your refusal to participate you differentiate yourself in the eyes of the customer - increasing the opportunity to win and keep business. The market determines whether this behavior is rewarded and by how much depending on customer behavior. Everybody gets a chance to decide for themselves, you and your customers.

However, if the bans are mandated top-down there is this presumption that "Big Brother knows best" and mug-free environment is better for everyone. Aside from the fact that the choice is taken away, there is simply no data to show that such bans do any good.

At the end of the day this is about appearances and perceptions, which IMHO unfairly cast shadow on healthcare marketing in general.

Submitted by Naomi on Sat, 01/10/2009 - 11:37am.

I know that drug companies spend a fortune to inform, encourage, and promote their products to physicians. I'd love to see them use this money to help physicians provide medication to their clients at no or lower cost. They can keep their note pads, lunches, cups and pens and provide more samples or credits to allow patients to get the medications they need  and continue to use them.

Marketing isn't a dirty word and as pointed out it is a form of informing and educating. It's the excess junk that is attached with the information. Informed, empowered consumers is the key to improving the quality of healthcare for everyone., in my opinion.

 

Naomi Giroux M.Ed.

Health Educator, Radio Show Host, Author

Submitted by Jason California (not verified) on Tue, 01/20/2009 - 1:39am.

It's not surprising actually. Remember, the health care is a business industry too. There is a need for them to sell and earn from its "beneficiaries." 

Submitted by Kevin Anthem (not verified) on Wed, 01/21/2009 - 12:41am.

I think the only imminent problem with excessive marketing is the misinformation it might create among people. Some people just don't know it any better and thus are willing to buy anything they see. In the end, it's still caveat emptor. It wouldn't hurt to make well-informed choices.

#8: Agree
Submitted by Taylor (not verified) on Fri, 02/20/2009 - 12:40pm.

I agree with the comment above. When insurance companies market based on premium along it usually means the health plans have holes in them. Sure, the premium is attractive but then you have holes in your policy that leave you high and dry when you have an accident. That is why there will always be a need for health insurance agents...they will let you know the pitfalls and help you deconstruct well marketed plans that seem like a great deal.

Submitted by Anonymous (not verified) on Tue, 02/24/2009 - 9:14pm.

There is a serious problem with marketing in the health insurance industry. Of course every company magically has "the best" rates because they want your business. The problem I have with the carriers is when they drop the monthly premium so low that it attracts you to buy they don't make it clear what benefits you are dropping. http://www.jclis.com

Submitted by Anthem California (not verified) on Thu, 06/25/2009 - 8:00pm.

Marketing isn't a dirty word and as pointed out it is a form of informing and educating. It's the excess junk that is attached with the information. Informed, empowered consumers is the key to improving the quality of healthcare for everyone., in my opinion.

Submitted by vitamin b (not verified) on Mon, 10/05/2009 - 4:16am.

Really a great post!

Pharmaceutical marketing, some say, has benefited by the recent
"dramatic drop off of enforcement of domestic laws." Under a Democratic
administration, they say, there will be a new emphasis on enforcement
of current regulations as well as new regulations.

The
drug industry's response has been to increase self-regulation, but
Dmitriy Kruglyak of Trusted.MD Network thinks this is cave in to
hypocritical attacks by the media and other critics of the industry

Submitted by personal loans (not verified) on Wed, 12/28/2011 - 2:10am.

I strictly recommend not to wait until you get enough amount of cash to buy different goods! You should get the business loans or just short term loan and feel yourself free



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