Correspondence
Direct-to-Consumer Marketing
N Engl J Med 2002; 346:2010-2013June 20, 2002
- Article
To the Editor:
There is a conflict between the conception of health care as a free-market economic process and the notion that health care represents one of society's obligations to its citizens. We cannot have it both ways. Physicians are also caught between these two incompatible views.
In a free-market system, physicians charge whatever the market will bear and limit the amount of charity care they provide in order to maintain profitability. Those who cannot pay simply do without care. Drug companies and owners of high-technology machines hawk their wares in any way they wish (including direct-to-consumer marketing as discussed in the Feb. 14 issue1-4), and for consumers, the watchword is “Buyer beware.”
If society recoils from the heartless consequences of a free-market system, we must cope with providing necessary care without regard to ability to pay. If every citizen is entitled to all types of medical care when they are needed, then we need a system that taxes all of us in order to support that entitlement. We need to determine which services, supplies, drugs, and tests must be included and which will be excluded. We need to determine what the payment to physicians will be, remembering that if the payment is too low, we will lose good physicians. We should use evidence-based studies to educate physicians and consumers about the costs and benefits of services, drugs, and tests.
4 ReferencesSarah K. Weinberg, M.D.
17330 135th Ave. NE, Woodinville, WA 98072
weinbergsk@msn.com 1
Rosenthal MB ,Berndt ER ,Donohue JM ,Frank RG ,Epstein AM . Promotion of prescription drugs to consumers. N Engl J Med 2002;346:498-505
Full Text | Web of Science | Medline2
Wolfe SM . Direct-to-consumer advertising -- education or emotion promotion? N Engl J Med 2002;346:524-526[Erratum, N Engl J Med 2002;346:1424.]
Full Text | Web of Science | Medline3
Holmer AF . Direct-to-consumer advertising -- strengthening our health care system. N Engl J Med 2002;346:526-528
Full Text | Web of Science | Medline4
Lee TH ,Brennan TA . Direct-to-consumer marketing of high-technology screening tests. N Engl J Med 2002;346:529-531
Full Text | Web of Science | Medline
To the Editor:
Pharmaceutical firms and medical entrepreneurs are not the only ones marketing directly to consumers. Recently, many professional societies have expanded their advocacy agendas. The purpose of these campaigns is in part to inform consumers and in part to increase demand for the services offered by members of the professional society. The American College of Gastroenterology produced a television announcement urging people over 50 years of age to be screened for colon cancer. The American College of Physicians created advertisements promoting their “brand” of doctors (internists) and distinguishing them from family practitioners. The American Dental Association launched a national campaign warning consumers, “Don't let it grow up to be oral cancer”; the campaign was funded by OralScan Laboratories, the manufacturer of a brush-biopsy test. Because consumers may not discern self-interest in advice from doctors, these advertisements can be more ethically and legally troubling than the practices described by Rosenthal et al.1 and Lee and Brennan.2
Should professional societies recuse themselves from speaking out on important health issues? Not necessarily. Offering information to health care consumers can improve health, even as it increases the demand for medical services. For example, marketing immunizations both gets children into pediatricians' offices and serves public health. Explaining the competencies and expertise of their members also seems to be a proper role for professional societies. But when professionals recommend specific actions to consumers, they should be certain that these actions are grounded in firm evidence of medical efficacy and cost effectiveness. When the balance tips toward financial self-interest, consumers and regulators may appropriately start treating professionals no differently from the way they treat for-profit companies.
2 ReferencesDavid Ackman, M.D., M.P.H.
Nassau County Department of Health, Mineola, NY 11501
dackman@health.co. nassau. ny. us Sherry Glied, Ph.D.
Mailman School of Public Health, New York, NY 100321
Rosenthal MB ,Berndt ER ,Donohue JM ,Frank RG ,Epstein AM . Promotion of prescription drugs to consumers. N Engl J Med 2002;346:498-505
Full Text | Web of Science | Medline2
Lee TH ,Brennan TA . Direct-to-consumer marketing of high-technology screening tests. N Engl J Med 2002;346:529-531
Full Text | Web of Science | Medline
To the Editor:
Although there may be advantages and disadvantages to direct-to-consumer advertising of prescription drugs, the main point to be considered is that such advertising helps to promote the empowerment of patients. Direct-to-consumer advertising of prescription drugs is illegal in many countries, including Portugal. Recently, an advertising campaign was launched by Portuguese authorities promoting the prescription of generic drugs. The campaign included advertising on television and in newspapers. For example, in one major newspaper, three complete pages were used to advertise generic drugs that are currently on the market. Such advertisements may be taken as a subtle form of direct-to-consumer advertising of prescription drugs that probably aims to reduce the pharmaceutical budget of the Portuguese state.
José Pedro L. Nunes, M.D.
Institute of Pharmacology and Therapeutics, 4200 Porto, Portugal
jplnunes@med.up. pt To the Editor:
Despite the statistics that are quoted by Alan Holmer of the Pharmaceutical Research and Manufacturers of America in his editorial,1 I do not believe many of the statements he makes. For instance, I do not believe that advertising a drug on television does not increase the cost of the drug to the patients who use it. If a pharmaceutical company believes that, then it needs new auditors. I do not believe that advertising a drug on television always leads to a useful discussion between the patient and his or her doctor. Even when the discussion does take place, the doctor may have trouble talking the patient out of using the “new and better” drug. After all, the patient discovered the miracle drug in a good magazine and “learned” a lot about it when it was presented on television. The artwork was so beautiful and the message so clear that the patient believes every word of the advertisement and assigns little value to what the doctor says. Holmer states that the purpose of the advertising is “rather to encourage an informed discussion between patient and physician.” I believe that the purpose of the advertisements on television and in magazines is to sell drugs — just as companies use such advertisements to sell soap and toothpaste.
1 ReferencesJ. Willis Hurst, M.D.
Emory University, Atlanta, GA 303221
Holmer AF . Direct-to-consumer advertising -- strengthening our health care system. N Engl J Med 2002;346:526-528
Full Text | Web of Science | Medline
To the Editor:
Drs. Lee and Brennan state that screening tests must have a high sensitivity, have a low false positive rate, and be useful for therapeutic decisions or reassurance, depending on the results. These criteria are understood by preventive cardiologists and lipid specialists who practice in this field to be salient features of electron-beam computed tomography (CT). Such “plaque imagers” have asserted that electron-beam CT produces essentially no false positives while offering virtually 100 percent sensitivity for detecting coronary calcium, a recognized marker of atherosclerosis. In outcome studies1 (except for a heavily criticized report involving high-risk elderly adults), the calcium score has been shown to be a powerful predictor of coronary events and to have incremental prognostic value beyond the identification of conventional risk factors.2 The unfortunate use of angiography as a gold standard by a writing group of the American College of Cardiology and the American Heart Association (only one of whose members had actual experience in coronary imaging) was roundly criticized by the Society of Atherosclerosis Imaging. Before a coronary event, electron-beam CT of the typical asymptomatic person would demonstrate a calcium score in the top quartile and would reveal no substantial obstruction.3 The authors would therefore misconstrue the test result as a false positive. Greenland et al.4 suggest that clinicians consider noninvasive testing for approximately 40 percent of adults in order to target for clinical risk-reduction measures those with “true risk” (who otherwise might be mischaracterized according to the guidelines of the National Cholesterol Education Program). If physicians referred patients for electron-beam CT when such examinations were indicated,5 instead of prescribing doctor-owned stress tests for patients with class III indications, the need for marketing might largely disappear.
5 ReferencesJames E. Ehrlich, M.D.
University of Colorado School of Medicine, Denver, CO 80206
telemed@earthlink.net John A. Rumberger, Ph.D., M.D.
Ohio State University, Columbus, OH 43210Alan G. Wasserman, M.D.
George Washington University School of Medicine, Washington, DC 200521
Arad Y ,Spadaro LA ,Goodman K ,Newstein D ,Guerci AD . Prediction of coronary events with electron beam computed tomography. J Am Coll Cardiol 2000;36:1253-1260
CrossRef | Web of Science | Medline2
Wong ND ,Hsu JC ,Detrano RC ,Diamond G ,Eisenberg H ,Gardin JM . Coronary artery calcium evaluation by electron beam computed tomography and its relation to new cardiovascular events. Am J Cardiol 2000;86:495-498
CrossRef | Web of Science | Medline3
Raggi P ,Callister TQ ,Cooil B , et al. Identification of patients at increased risk of first unheralded acute myocardial infarction by electron-beam computed tomography. Circulation 2000;101:850-855
Web of Science | Medline4
Greenland P ,Smith SC Jr ,Grundy SM . Improving coronary heart disease risk assessment in asymptomatic people: role of traditional risk factors and noninvasive cardiovascular tests. Circulation 2001;104:1863-1867
CrossRef | Web of Science | Medline5
Hecht HS . Practice guidelines for electron beam tomography: a report of the Society of Atherosclerosis Imaging. Am J Cardiol 2000;86:705-6, A9
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Rosenthal and colleagues reply:
To the Editor: We agree with Ackman and Glied that the recommendations made by health care professionals and the organizations that represent them may affect their own financial interests. This is true both under traditional fee-for-service payment plans and in an environment in which physicians are paid by capitation, although the incentives are obviously different in the two situations. Self-regulation is a central tenet of professionalism. Physicians must be especially wary in situations in which the potential effect of their advice on their own financial interests is great.
The letter from Nunes is a reminder that direct-to-consumer advertising could contribute to improved patient care and, in some situations, could even reduce the cost of care. One can imagine similar educational campaigns by managed-care organizations or the generic-drug industry in the United States to promote the use of less expensive medications.
Finally, we share Weinberg's support for universal coverage but believe that it could be accomplished without the elimination of “the market,” at least in terms of delivery. Many countries have achieved this goal while maintaining market incentives. The key is a nationally shared commitment to providing health care for all our citizens.
Meredith Rosenthal, Ph.D.
Harvard School of Public Health, Boston, MA 02115
mrosenth@hsph.harvard. edu Richard G. Frank, Ph.D.
Harvard Medical School, Boston, MA 02115Arnold M. Epstein, M.D.
Harvard School of Public Health, Boston, MA 02115Author/Editor Response
Drs. Lee and Brennan reply:
To the Editor: We agree with Ehrlich and colleagues that use of electron-beam CT should be targeted at patients for whom it is most likely to provide information that will improve their care. However, we do not believe that any such population of patients has been identified through rigorous research to date. There is little question that calcium scores correlate with prognosis for asymptomatic patients, but two questions remain unanswered: Can electron-beam CT improve risk predictions that are based on the thoughtful analysis of clinical data? And does treatment of asymptomatic patients with high scores on electron-beam CT reduce their risk of complications of coronary heart disease? Until both of these questions can be answered in the affirmative, we believe that it is inappropriate for physicians to be marketing electron-beam CT directly to consumers or performing electron-beam CT outside of research protocols.
Thomas H. Lee, M.D.
Troyen A. Brennan, M.D.
Harvard Medical School, Boston, MA 02115
thlee@pchi.partners. org Author/Editor Response
Dr. Wolfe replies:
To the Editor: Nunes implicitly discusses the difference between direct-to-consumer advertising, the main purpose of which is to sell brand-name prescription drugs, and accurate direct-to-consumer information, the purpose of which is to empower patients with information that will be of benefit to them. The case of the Portuguese government's campaign to educate the public about the economic advantages of generic drugs is an excellent example of the latter — one that the U.S. government should replicate. Other examples would be widely publicized government campaigns, involving the Food and Drug Administration and the National Institutes of Health, to educate patients and physicians with accurate and up-to-date information about the preferred treatments for various common diseases.
Ackman and Glied point out that the concept that financial conflicts of interest may cloud the veracity of information is not limited to the pharmaceutical industry but has infected what I believe must be the overwhelming majority of organizations for physician specialties and subspecialties. As medicine increasingly becomes a business, with money too often trumping the basic, historical service ethic of our profession, the credibility of medical organizations and physicians themselves is endangered by the increasing documentation of decisions made not solely on the basis of what is in the best interest of the health of the patient but also on the basis of what may be most beneficial financially to doctors and their organizations.
Sidney M. Wolfe, M.D.
Public Citizen Health Research Group, Washington, DC 20009
swolfe@citizen.org
