Saturday, January 16, 2010

Cancer Care and Hospital Advertising

The December 19, 2009 issue of the New York Times contains an article entitled Cancer Center Ads Use Emotion More Than Fact. The piece, by Natasha Singer, documents the extensive use of advertising by hospitals to attract cancer patients, and decries the appeal to people’s emotions at a time of great vulnerability, after they have received a cancer diagnosis. These appeals contain testimonials from people who were “cured” or had a good outcome (or at least think, at the time of the testimonials, that they had a good outcome), and imply – sometimes frankly state – that their cancer care is better than their competitors’. Those competitors may be other hospitals in the same metropolitan area, or, in the case of centers that have received special National Cancer Institute (NCI) “cancer center” designation, or in the case of the “top” centers (e.g., MD Anderson in Houston, Dana-Farber in Boston, in New York ) each other.

The issue is that this advertising does not have to be based on fact. This is not to say that the actual people in the testimonials are lying, but that there is no requirement for data on statistical outcomes from these hospitals before they produce their advertising. The individual patient may have had a good outcome, but has no way of knowing if the outcome would have been as good (or better) somewhere else. The article documents assertions of superlatives, such as a doctor having the “highest cure rates” and “lowest risk”, which a reasonable person might infer was based on data comparing that doctor’s, or that hospital’s, results to others. However it turns out that they are based on anecdotes, something that would be completely unacceptable in the reporting of scientific results. One expert noted that “There seems to be a disconnect between the business end of the cancer treatment industrial complex and the physicians on the front lines treating patients,” a dramatic understatement. “This isn’t retail advertising,” said the president of a Manhattan agency that developed ads for Mount Sinai hospital, “This is reputation advertising. There is a very big difference.”

Why hospitals want to advertise their cancer care (or their care for any other profitable “service line” such as, the article notes, cardiovascular disease or cosmetic surgery) is obvious – to make money. Though most of them are “not-for-profit”, all that means is that the “profits” don’t go to shareholders, but they can certainly be used by the hospital for expansion or creations of new and better service lines. And higher salaries and bonuses for executives (and physicians). Does it improve people’s health? Well, to a certain degree competition between hospitals does; like competition in any industry it operates against complacency, against “doing what we’ve always done”, against being satisfied with less than “the best”, because if it is possible to do better, there is the chance that your competitor will do better, and take away your business. It is also reasonable to advertise, so that people know how well you are doing. However, when the advertising is not based on real outcomes data, but purports to be, that is, it indicates – possibly not knowingly untruthfully but without evidence to back it up – that is at best misleading, and possibly unethical.

From a health perspective, a community needs a certain capacity for care of cancer patients – or any patients. That community may be a part of a city, or a city, or a metropolitan area, or in the case of rarer cancers, a region or even the nation. Excess capacity is extremely costly – if hospital A gets most of the cancer “business” in town, so hospital B chooses to invest heavily in building a new cancer-treatment facility (including, by the way, with public funds, since because they are not-for-profit, donations are philanthropy and tax-deductible), we now have excess capacity in the community, and a great deal of extra cost. To the extent that this represents a competition that results in better care, as discussed above, it may be a good thing – but the hospitals should have to document that there is actually better care provided, something almost never done. And, if it is going to spend a lot of money to create excess capacity in the community, the hospital should have to use the traditional method of raising capital and not be able to use tax-deductible contributions for this purpose (but, of course, they do).

There is another problem, which I mentioned briefly above. Hospitals do not heavily (and possibly deceptively) advertise all their services; like other businesses they advertise the profitable services. In general, services (“product lines”) are profitable because the current payment system reimburses for these services far more than the cost of delivering them. Cancer is in this category, because of the enormous markups for providing chemotherapy drugs (this is in addition to the enormous markups charged by the manufacturers). So are cardiovascular procedures, neurosurgical procedures, and of course cosmetic surgery. Hospitals do not heavily advertise the care that they provide (even if it is in fact excellent and better than others’ based on real data) if they don’t make as much, or even lose, money. This includes “regular” medical diseases, as well as very costly special services including much trauma and burn care. Pediatrics is a special case; in general (other than, of course, pediatric cancer care, for the same reasons as adult cancer care, and neonatal intensive care) does not make money, so general hospitals don’t heavily advertise it. “Children’s Hospitals”, however, are often among the greatest recipients of philanthropy in a community, and this is their main source of revenue, so advertising what they do makes sense for them in order to keep their name in front of donors.

We have become used to hearing (including from me) cautions about the greed and influence of the health insurance and the pharmaceutical and device manufacturers on health care, on health legislation and on politicians. These companies are for-profit and interested in their bottom lines, not on the impact that they have on health itself. Much of this is discussed in the New York Times article Health Lobby takes fight to the states on December 29, 2009, but as I have noted, it is the health care industry lobby, not the health lobby. We would have hoped that our communities’ hospitals would see themselves as more interested in our health, but this sort of advertising makes it clear that, non-profit though they may be, they are the health care industry.

Where does this leave us? It leaves us with the need to develop, and publicly report, good measures of outcomes for physicians and hospitals, as called for by many experts, notably Institute for Healthcare Improvement director Don Berwick, MD[1]. Otherwise people will continue to choose hospitals and doctors based on reputation and the quality of their “hotel facilities” rather than on the quality of their care. Pending that, we need to remember to see all health care advertising, including that from doctors and hospitals, as precisely that, advertising, and not confuse those claims with the scientific evidence that we hope will guide our care.

[1] Berwick, D., “Measuring physicians’ quality and performance: adrift on Lake Wobegon”, JAMA Dec9,2009;301:2485-6

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