A recent television ad for Cancer Treatment Centers of America features a real patient, Sybil Redmon, who is suffering from pancreatic cancer. During the ad, Redmon raves about the hospital chain’s religious resources, which include a pastor on staff who will pray with patients. The ad promises “advanced medicine and technology, the warm embrace of the spirit,” and Redmon says she believes God led her to that particular cancer center. Other ads for Cancer Treatment Centers feature happy patients talking about advanced therapies they received, often with great success. The only disclaimer in the ad consists of two sentences that appear briefly on the bottom of the screen: “No case is typical. You should not expect to experience these results.”
Ads such as these have generated a lively debate in the medical and business communities. On one side are free-commerce advocates who say hospitals should be able to advertise just like any consumer products maker can. On the other are those who believe the proliferation of health care advertising raises serious ethical issues that need to be addressed. One group of faculty from the University of Pittsburgh and Carnegie Mellon even went so far as to publish an article early this year in the American Journal of Bioethics suggesting that the risk that hospital ads will mislead patients is so great that hospitals should be subject to the same regulations that govern ads for prescription pharmaceuticals.
Before contemplating the possibility of hospital ads including a laundry list of risks like drug ads do, it’s worth looking at the proliferation of health care facilities that have turned to direct-to-consumer marketing. The trend is being driven not just by national chains like Cancer Treatment Centers, but also by local hospitals. In the first quarter of this year, total ad spending on local services grew 7.1% to $2.4 billion — with hospitals, medical centers and doctors’ clinics driving most of the increase — according to Kantar Media, a New York-based communications consulting firm.
Why are health care facilities reaching out directly to consumers now? Robert Town, professor of health care management at Wharton, says consumers have more power now than they did in the past to choose where they’re treated. Health reform is partly responsible, in that the emergence of health exchanges has bolstered the general concept of being able to shop in a health care marketplace, he notes. “Consumers are probably being a bit more active in the selection of which hospital they’re admitted to and where they seek care, whereas in the past that decision was driven by the physician. Now that consumers are more activated, there’s room for other influences in that decision. Advertising can be one of those.”
Happy Anecdotes vs. Real-world Data
For most of this country’s history, hospitals didn’t advertise their services. That’s because the American Medical Association banned the practice in its 1847 code of ethics, which declared the practice “derogatory to the dignity of the profession.” It took until 1980 for that ban to be reversed, which it was when a circuit appellate court ruled that the AMA could no longer place restraints on advertising. Such bans, it said, violated the Federal Trade Commission Act protecting free commerce.
“They’re telling you the one good case without telling you how many didn’t work or weren’t so successful.” –Ezekiel Emanuel
Many physicians are nostalgic for the days when marketing health care directly to consumers was considered unethical and unprofessional, including Wharton health care management professor Ezekiel J. Emanuel, whose experience as a physician included serving on the faculty of the Dana-Farber Cancer Institute in Boston. “Advertising is really just about rearranging market share. I understand it’s a business practice. But it’s not a professional practice,” Emanuel says. “It’s not really about ensuring the health of the community. And I think that’s what is essentially frustrating to people.”
In the American Journal of Bioethics piece, University of Pittsburgh physician Yael Schenker and her co-authors spotlight a number of concerns, including the fact that ads featuring patients who were cured by the hospitals they are praising do not include information about the risks presented by the procedures they underwent, or the overall success rates for such procedures. Furthermore, by focusing some ads on “indirect benefits” — think religious care offered, for example — they may be inappropriately deflecting attention away from questions of quality.
Emanuel points out that the basic nature of advertising makes it unreasonable to expect hospitals to do anything differently, even though the basic formulas they use in the advertising would be deemed unethical by many in the medical community. “What would you expect them to put up except an anecdote that’s favorable to them? Ads are meant to sway people, they aren’t meant to give people data,” Emanuel says. “What isn’t there is the overall quality of a system, measured in some objective way. They’re telling you the one good case without telling you how many didn’t work or weren’t so successful. They’re not lying, but they are distorting things in a different way, which is by not telling you the full story. The way the statisticians would put it is they’re giving you a numerator without the denominator.”
Physician as Go-between
Not everyone believes hospital ads are all that powerful in swaying health care decisions, largely because patients rarely make those decisions in a vacuum. “I think one thing we’re missing here is that there are physician agents who are still in a position to steer patients. I don’t think we should forget about that,” says Jonathan Kolstad, a Wharton health care management professor. “It’s more important to provide those physicians with information to either support or conflict with the perception coming out of advertising than it is to have a lot of regulation around hospital ads.”
There’s little doubt that placing similar advertising restrictions on hospitals that are placed on drugmakers would be challenging. Prescription drug ads are regulated by the U.S. Food & Drug Administration, which requires that direct-to-consumer pitches include “fair balance” — meaning the information about a drug’s risks must be equivalent to information given about its benefits. That’s why the typical TV drug ad ends with a rather long recitation of scary-sounding side effects.
Problem is, the risks of being admitted to particular hospitals aren’t so cut-and-dry, which could make it impossible to present a fair balance in ads for health care services. Drug companies run multiple clinical trials, from which they generate plenty of data about the risks of new drugs. It’s not so easy for hospitals to do that, and overall data on health care outcomes is notoriously unreliable and difficult to access anyway.
“It matters how much incremental difference there is across locations, where there can be a lot of variation in quality,” Kolstad says. “What’s important is demonstrating the incremental value or lack of value in a particular hospital, and that’s a much more nuanced issue.”
The risks of being admitted to particular hospitals aren’t so cut-and-dry, which could make it impossible to present a fair balance in ads for health care services.
Besides, Kolstad adds, disclaimers amount to little more than fine print, so overburdening them with data on risks or overall experiences of other people with their diseases wouldn’t do much good. “I think this comes back to this role of agency. The physician is clinically trained and should be able to interpret information that’s more nuanced. It’s not clear to me that giving fine print to consumers is the way to go. Rather, we should strengthen the mechanisms we have in place in health care to overcome information problems.”
The University of Pittsburgh’s Schenker found in her research that disclaimers can actually backfire. She uncovered two studies that showed disclaimers increased consumers’ vulnerability to the advertising message, because viewers figured the warnings signaled that the ads had been vetted by someone with the expertise to determine their accuracy. “There’s been some interesting work done showing that merely having a disclaimer there can lead to a sense of relief, as in, ‘Oh good, I no longer have to worry about the facts being deceptive,’” Schenker says. “So I don’t think the issue of disclaimers is clear-cut.”
Peter Yesawich, chief marketing officer for Cancer Treatment Centers of America, points out that his company is one of the few that places any disclaimers in its ads. Furthermore, most of the ads encourage viewers to visit the company’s website, where they can examine data pertaining to treatment results for 11 types of cancer compared to national results — data that the hospital chain is not required to provide.
“That’s a very bold initiative on our part,” Yesawich says. “We don’t necessarily exceed all of the national averages in terms of survival rates in all 11 types of cancer. But it’s not as if we don’t disclose it. We want people to be informed about the efficacy of our treatments.” Yesawich adds that he wouldn’t necessarily oppose legislation to require such transparency in all hospital ads, though he’s concerned about the overall lack of reliable national data on health care outcomes.
Schenker suggests that before any legislation is considered to limit hospital advertising, more research needs to be done to answer some basic questions, such as what are hospitals spending on these ads, and what is the contribution of health-services advertising to overall health care costs?
Kolstad agrees, and suggests that the health care system should focus less on the question of whether the ads harm consumers and more on the issue of whether they’re driving up health care costs. “A lot of what’s happening is hospitals are advertising new, capital-intensive, high-tech equipment,” he says. “That could be very informative, and it could increase the speed by which new treatments are made available to more people. On the other hand, if all it does is induce demand for high-cost technologies that are of little or no incremental value, then this could be very detrimental.”
Drawing Attention away from Quality
As for the question of whether it’s ethical to focus hospital advertising on ancillary benefits, such as the cleanliness of the waiting room or the availability of pastors to pray with patients, not everyone agrees with Schenker’s assessment that such details can be harmful. Wharton’s Town points out that health care institutions traditionally were thought of as notoriously unresponsive to patient needs. Ads that focus on the soft side of medicine are “a sign that’s something good is happening. Hospitals are showing that they’re not just workshops of physicians and executives, but that they’re actually trying to make the patient experience better.”
“What’s important is demonstrating the incremental value or lack of value in a particular hospital, and that’s a much more nuanced issue.” –Jonathan Kolstad
Town adds that proposals to limit hospital advertising don’t give consumers enough credit for being able to take the information they’re getting with a grain of salt. “I think consumers understand that companies are putting their best foot forward, whether the products they’re advertising are hospitals or consumer electronics. Consumers understand they’re only getting some aspect of the story.”
Penn student Moti Gorin, who’s currently completing a two-year post-doctoral fellowship at the Perelman School of Medicine’s department of medical ethics and health policy, was so captivated by Schenker’s paper that he wrote a response, which was published by the American Journal of Bioethics in March. Gorin says he shares some of the concerns that have been raised about hospital advertising, but he disagrees with one of Schenker’s central arguments, which is that hospitals have a fiduciary responsibility to patients that they may be violating by running ads.
“Typically, we think of a fiduciary relationship as one that’s been established because of the roles of the people involved: a doctor and a patient, a financial advisor and a client, and so forth,” Gorin notes. “In cases where a health care provider like a hospital is trying to recruit new patients, the typical fiduciary model doesn’t really apply. If I’m riding the train and I see a billboard advertising a hospital, what obligations does that institution have with respect to me? I suggest that it’s not fiduciary, because they’re not my health care provider.”
That said, Gorin favors of an all-out ban on hospital ads. “There are a number of concerns here. Patients are oftentimes ill, and in some cases they’re desperate. So they’re going to be particularly vulnerable to the kinds of influences advertising can sometimes exert,” Gorin says. “Another concern is the lack of information. Advertisements on billboards or in 30-second spots on television and radio can’t provide prospective patients with the kind of information they need to make informed choices.”
Maybe so, but Emanuel warns that we shouldn’t expect the government to step in with an all-out ban, or even with regulations restricting hospital advertising anytime soon. “It was the government that opened up the advertising on drugs,” Emanuel says. “So the idea that they’re going to restrict this I just don’t think is realistic.”