Madison Avenue Medicine

excerpted from the book

Critical Condition

how health care in America became big business - and bad medicine

by Donald L. Bartlett and James B. Steele

Broadway Books, 2006, paper


Each year, the U.S. Department of Health and Human Services conducts a nationwide survey on the medical well-being of the American people. The 2003 study, like the ones before it, showed that most of us think we are in good health. In fact, 35.5 percent of those questioned assessed their health as "excellent," and another 31.9 percent labeled it "very good." Similar findings a year earlier buttressed the underlying health statistics that prompted Surgeon General David Satcher to sound a positive note. "In many ways," Satcher said, "Americans of all ages and in every racial and ethnic group have better health today."

But if two-thirds of the population rates their health as excellent or very good, how is it that so many of us are sick? In fact, by some accounts we may be the sickest people on the face of the planet. At least that's what we're being told by television and radio reports and commercials, newspaper and magazine articles and advertisements, medical foundations, universities, and the health care community itself. The numbers are breathtaking.

"Approximately one hundred million Americans have excessive levels of total cholesterol," the American Heart Association warns. "More than sixty million American adults experience GERD [gastroesophageal reflux disease]," according to FDA Consumer. "Ten million individuals are estimated to already have [osteoporosis] and almost thirty-four million more are estimated to have low bone mass," the National Osteoporosis Foundation claims. "About 3.8 million kids have Attention Deficit Hyperactivity Disorder (ADHD)," the American Academy of Pediatrics reports. "More than nineteen million Americans suffer from some kind of anxiety disorder," the Anxiety Disorders Association of America contends. "Somewhere between forty-five million and sixty million Americans now have the genital form of [herpes]," maintains Drug Topics. "An estimated twenty-five million adults have incontinence... significant enough to make it difficult for them to maintain good hygiene and carry on ordinary social and work lives," the Harvard Medical School reports.

There's more: The Johns Hopkins Medical Institutions say thirty-five million people have irritable bowel syndrome. The American Association of Clinical Endocrinologists says thirteen million Americans have thyroid disease. Medical Devices & Surgical Technology Week says nine million men suffer from benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate gland. The CDC says nearly seventy million adults suffer from chronic joint pain. Biotech Business Week says more than two million Americans have atrial fibrillation, a common arrhythmia that can result in an abnormally fast heart rate. The American Liver Foundation says twenty-five million people have a liver disease. NBC's Today Show says two million people have hyperhidrosis, a genetic problem that causes abnormal sweating. The National Institutes of Health says twelve million people have chronic obstructive pulmonary disease and twenty-four million have impaired lung function.

Then there's latent tuberculosis infection, ten to fifteen million people; male impotence, thirty million men; rosacea, fourteen million people; eating disorders, eleven million; fibromyalgia (chronic pain in muscles and tissues around joints), six million; obesity, sixty million;

Alzheimer's, four million; chronic headaches, forty-five million; psoriasis, seven million; peripheral arterial disease, thirty-four million; hypertension, fifty million; clinical depression, eighteen million; peptic ulcers, twenty-five million; chronic kidney disease, twenty million; allergies, forty million; sleep disorders, seventy million; restless legs syndrome, twelve million; and excessive menstrual bleeding, ten million women.

To be sure, this litany overlaps in certain areas. Some of the 58.4 million with high blood pressure most likely are among the sixty million with cardiovascular disease. On the other hand, this list is far from complete, omitting scores of diseases, disorders, and conditions from cancer to chronic fatigue syndrome. If all those said to be suffering from some ailment are taken into account, it's estimated there are more than 1.5 billion sick people in the United States-or five times the population. Assuming one-third are in the "excellent" health they claim, then two out of every three people you pass on the street are walking around with at least eight different maladies.

Are Americans really that sick? Of course not. So what's going on here? Simply put, it is in the best interest of a market-driven medical system to make you think you are sick, or soon will be, or worry you over the possibility. The grossly exaggerated numbers are in the best interest of everyone-everyone except the public. For drug companies that offer multiple pills for every affliction, real or imagined, they mean billions of dollars for the bottom line, which helps explain why they are the country's most profitable businesses year in and year out. For doctors and hospitals, those inflated numbers mean more billions in revenue. For Madison Avenue, newspapers, magazines, television, and radio, they mean billions in advertising revenue and commissions, as well as increased ratings and sales. For testing laboratories and manufacturers of expensive diagnostic equipment, such as MRI machines, they mean more billions in revenue. For special-interest groups, they mean billions in permanent funding for a bloated health care bureaucracy. For members of Congress, they mean campaign contributions and positive headlines as lawmakers wage a perpetual crusade on behalf of the sick. For celebrities raising funds for their favorite disease, they mean endless publicity and generous fees.

As more individuals are encouraged to ask their doctors to examine them for conditions they don't have and treat them for nonspecific ailments, they become an ever-growing drain on public and private funds. The United States already wastes tens of billions of dollars on needless visits to doctors' offices, unnecessary or excessive medical tests, over-diagnosis, over-treatment, needless surgical procedures, and the unwarranted dispensing of prescription drugs on a titanic scale, thereby turning the country into the world's pill capital.

The personal price tag for all this is staggering. The paychecks of workers continue to shrink as they are compelled to pick up a larger share of health insurance premiums and co-pays. People with serious diseases are priced out of the insurance market. Companies tired of relentless health care cost increases are scaling back or canceling coverage for their employees and retirees. Saddest of all, the truly sick, the aged, the infirm, and families dealing with catastrophic illnesses are forced into poverty and bankruptcy.

A lot of money is being made by striking fear in the hearts of Americans that they will die prematurely unless they rush out and buy the latest medication. Few are profiting more from this tactic than the pharmaceutical companies, which hold the patent on profitability. New York-based Pfizer Inc., the world's largest pharmaceutical company, posted a 28.4 percent return on revenue in 2002. That was some

I four times better than ExxonMobil Corporation, nearly nine times better than Wal-Mart Stores, and more than thirty-one times better than General Motors Corporation.

On a scale no one could have foreseen, the drug companies have enlisted the expertise of Madison Avenue to sell you their wares. Using techniques advertising has perfected over decades to entice consumers to buy soap, cereal, beer, perfume, and dog food, the drug companies are transforming the way we look at medicines and fattening their own profits in the process.

From 1994 to 2000, spending for consumer drug advertising rocketed from $266 million to $2.5 billion-a whopping 840 percent increase. Sales of prescription drugs shot up from $79 billion in 1997 to $164 billion in 2002. At the present pace, sales will reach a quarter-trillion dollars by 2007. As a result of this runaway spending, overpriced prescription drugs are driving up health care costs for everyone. 'While drugs account for just 10 percent of the nation's total health care bill, they are the fastest-growing component. Between 1993 and 2002, spending for hospital care went up 52 percent and outlays for physician services increased 69 percent. But prescription-drug spending climbed three to four times faster-spiraling to 217 percent. This trend is likely to accelerate as the Medicare drug benefit takes effect fully in 2006, and Congress refuses to abandon a legislative policy that makes American consumers pay the highest prices in the world for prescription drugs.

The commercials are powerful, convincing, and, most of all, manipulative. If you're feeling perfectly healthy at the crack of dawn, by day's end you will certainly wonder if you might be suffering from one or more of the many maladies that are the subject of ads appealing to people's insecurities.

... Madison Avenue counts on the basic instincts of Americans to look for a quick fix, hoping that after taking in a couple of commercials you will begin gulping multiple pills so that you can enhance your sex life, calm your anxieties, postpone the aging process, reduce your blood pressure, heighten your concentration, build thicker bones, improve your blood flow, sleep more restfully, dull the pain in your shoulder, and slash your cholesterol to prevent heart disease-even though one-third of all people who die of heart disease actually have low cholesterol.

The medical mantra "Ask your doctor" has become one of Madison Avenue's most successful catchphrases ever. "Ask your doctor about Imitrex." Or "Ask your doctor about adding Plavix." Or "Ask your doctor about getting relief with Zelnorm." Or "Ask your doctor about Celebrex." Or "Ask your doctor about Zocor." Or "Ask your doctor if prescription Prevacid is right for you." Or "Ask your doctor about new

once-a-day Wellbutrin XL." The unrelenting commercials pitching pills for the treatment of everything from arthritis to high cholesterol end with the ubiquitous phrase. The commercials play on the trust that patients have in their doctors. Many doctors, in turn, say that when patients ask for a certain medicine by name, they feel pressured to prescribe it.

Truth to tell, doctors sometimes have little more independent understanding than you do about a particular drug. They derive their knowledge largely from advertisements similar to the ones that you see and from information supplied by the drug companies directly. An army of sales representatives, carrying armloads of samples, descend on doctors' offices daily. In addition, the companies hold seminars, take doctors to dinners, and distribute lucrative fees for serving as "advisors." The purpose of the ads and the personal contact is to sell a product, not to discourage its use by dwelling on what could go wrong. The drug companies spend many more billions of dollars on this marketing effort than on advertising.

While physicians read many of the reports on clinical trials or studies in medical journals, no one can read and absorb them all. There are not enough hours in the day to keep abreast of all the studies involving all the drugs that are available-and also see patients.

That's why doctors are as susceptible to advertising as you are. And always have been ...

Harry Loynd ,Parke-Davis & Company CEO in the 1940s

"Pills are to sell, not to take."

"If we put horse manure in a capsule, we could sell it to 95 percent of these doctors."

... the picture of the U.S. health care system today, thousands of individual entities heading off in many directions on missions that frequently conflict. It's really no system at all. Rather, it's a stunningly fragmented collection of businesses, government agencies, health care facilities, educational institutions, and other special interests wasting tens of billions of dollars and turning the treatment of disease and sickness into a lottery where some losers pay with their lives.

The United States has 6,000 hospitals and tens of thousands more freestanding medical centers, nursing homes, kidney dialysis centers, laboratories, MRI facilities, pharmacies, and medical schools. Each maintains its own computer system. Some can talk to one another; most can't. Overlying these are hundreds of HMOs, private insurers, and government plans. There's Medicaid for the very poor, Medicare for everyone over sixty-five years of age, TRICARE and the Veterans Administration for the military, and a hodgepodge for everyone else. Each insurer has its own system of co-pays, deductibles, and spending limits. Each produces thousands of pages of impenetrable language setting forth the medical expenses it will pay, the ones it won't, and those that fall somewhere in between.

Then there are thousands of special interests, from the American Cancer Society to the American Medical Association, from the Pharmaceutical Research and Manufacturers of America (PhRMA) to the American Organ Transplant Association, each with its own agenda. Each wages an individual campaign to shape health care policy by manipulating public opinion through TV newspapers, magazines, and radio. Each seeks to grab a piece of the health care pie. Out of all these thousands of self-interested entities, not one speaks for what's best for American health care overall.

And that explains why U.S. health care is second-rate at the start of the twenty-first century and destined to get a lot worse and much more expensive.

The simplest and most cost-effective remedy would be to provide universal coverage and to create one agency to collect medical fees and pay claims. This would eliminate the staggering overlap, duplication, bureaucracy, and waste created by thousands of individual plans, the hidden costs that continue to drive health -care out of reach for a steadily growing number of Americans.

Under a single-payer system, all health care providers-doctors, hospitals, clinics-would bill one agency for their services and would be reimbursed by the same agency. Every American would receive basic comprehensive health care, including essential prescription drugs and rehabilitative care. Anyone who needed to be treated or hospitalized could receive medical care without having to wrestle with referrals and without fear of financial ruin. Complex billing procedures and ambiguities over what is covered by insurance would be eliminated.

Radical? We already have universal health care and a single-payer system for everybody aged sixty-five and over: It's called Medicare. For years, researchers, think tanks, citizens' groups, and health care professionals have advocated a similar plan for the rest of the population. Study after study has concluded that the most practical and cost-effective way to provide quality health care and to restrain costs is a singlepayer system, but no plan has ever come close to adoption because of fierce opposition by the powerful health care lobby.

Critical Condition

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