DTC Advertising on TV illustrates the corruption and inequity of the US medical care system

I don’t watch a lot of live daytime TV. (In fact, I don’t watch a lot of live TV at any time.) I do see it several times a week for the 45 minutes I spend on the elliptical at the gym, which requires that the two TVs be tuned to sports. In practice, that means ESPN and ESPN2 and I try to position myself between them so I can look at whichever has the least boring talk. Daytime is not a time for actual sports; it is all sports talk. And mostly I listen to music in my headphones.

But I did seem to notice a really lot of the commercials were medically-related and aimed at my demographic (ie., “old”). Since I was recently in the hospital for several days and had the TV on different stations, I can attest that this pattern is not limited to sports shows; it is absolutely as ubiquitous on CNN, MSNBC, etc. (can’t personally attest to FoxNews, but I bet it is also true there). Sure, there are a few non-medically related commercials aimed at my demographic (e.g., reverse mortgages) and once in a while even something of more general generational interest – I particularly liked a half-hour infomercial for the NuWave Bravo air fryer/convection oven. But the medically related dominate.

Such commercials include those related to insurance (Medicare supplements and in particular Medicare Advantage – which seems a bit odd, since open enrollment doesn’t start until October), those advertising medical treatments for disease of the age-challenged, and lots of commercials for incredibly expensive recombinant DNA (anything ending in “-ab”) for relatively uncommon diseases. This last group is in the traditional (if your idea of “tradition” is 40 years) mode of direct-to-consumer (DTC) advertising first legalized under the Reagan administration: “ask your doctor if this is right for you”. The implication is that it probably is, although the litany of unpleasant side effects that always starts with bloating, and moves to serious infections, and ends in death, should give us pause. It is certainly right for the drug manufacturer, who – shock! – makes HUGE HUGE HUGE amounts of money on these things. Some of these drugs cost $100,000 a year. There are neurologic drugs that cost $30,000 a MONTH. Or more. Thus it is worth advertising to lots of people in the hope that even a small percentage will “bite”.

NOTE: Most doctors hate this DTC advertising. Yes, it is in part because of how irritating and time consuming it is for patients to come in and keep asking about whether they should be on these drugs. But more important, it is because they are trying to take care of you, to best manage you condition using drugs (when drugs are appropriate) that are the most effective, have the fewest and least dangerous side-effects, and are affordable for you. Why on earth anyone would ever think that a multi-drillion-dollar multi-national drug company would have your health interests at heart more than your doctor? If you think that, 1) you’re wrong, 2) you’ve been watching too much TV.

In addition to the insurance and drug commercials, there are multitudes of miscellaneous others, especially for devices. You can get an app for your phone that will check your EKG. You can get endless numbers of devices that will monitor your blood sugar, many of which apparently come with the added benefit of turning you into a totally fit mountain biker! Indeed, if you have always wanted to play the flute, direct a play, or kayak whitewater, these devices are for you! Also, the you-know-what. And let’s not forget the “mobility devices” like scooters, available at “no cost to you” (although such ads seem a little less common since some of the big operators have been imprisoned). These commercials provide a regular source of income for actors in their 50s playing people in their 70s. Even the ones in scooters look not very old, not very sick, and not very obese. Of course, sometimes they feature a real person in their 70s, if they’re famous. Joe Namath, is, I think, 77.

There seem to be endless ways for the companies to make money off of your Medicare benefit. Medicare Advantage is one issue that deserves a little more discussion, since they often seem to (and may) offer you actual advantage. Medicare Advantage (Medicare Part “C”) takes the money that traditional Medicare would pay, usually has you put in more, and basically puts you in an HMO. You get the benefits of an HMO – stuff not covered by traditional Medicare like maybe eye, ear, dental, or other stuff. Also, the disadvantages, like limited choice of doctors, hospitals, etc., especially if you’re not in your usual geographic area. People with traditional Medicare do not get bills from doctors who are out of network (unless, and this is rare, they have opted out of Medicare altogether), but Medicare Advantage patients do. So, if you never leave your home area, and are happy with the hospitals and doctors in the network, it may be a good choice for you, just as an HMO may be for anyone (disclaimer: probably, however, if you are to choose one, it shouldn’t be the one advertising on TV!)

That’s about you, though. Societally, it is much worse. Medicare Advantage plans, compared to traditional Medicare, have way higher overhead costs (about 12-18% vs about 2%). They also get paid extra by the federal government. Why? Well, you’d have to ask Reagan and his GOP successors; essentially it is part of an effort to privatize as much as possible. And, like most efforts to privatize, actually costs more. And we all, as taxpayers, pay for it.

This is not a benign process, for Medicare, for drugs, for devices. They are selling us very expensive stuff and making a huge profit, while millions of Americans have no health insurance and millions more are grossly underinsured. Discussions about national health insurance proposals often focus on cost, but the stuff being sold in these commercials is part of the structure that causes amazingly inflated costs, making our health system the most expensive (2-3x as much per capita as other industrialized countries) while maintaining among the worst health outcomes of that group of nations. And the burden is not spread equally; those most in need, those who are the poorest, disproportionately minority group members, are the hardest hit. It is inequitable, discriminatory, and immoral.

The bottom line is that all of these commercials propagate a system that is not only vastly inequitable, but is medically inappropriate. A system in which the goal is not to maximize the health of the population, in any fashion but certainly not an equitable one, but rather to maximize the profit for the companies that are advertising, to take money from the rest of the economy and accrue it to themselves. This, of course, is the nature of modern capitalism, but that doesn’t make it good. You have to decide if your health, and the health of your friends, family, community and nation are a core public benefit or a product to be sold, caveat emptor.

The bottom line for the individual is the same as it is for all commercials. They are NOT about YOU. They are about MAKING MONEY for the company sponsoring the commercial. That is all. You are nothing but the vehicle, or perhaps more technically, “sucker”, who will channel that money their way. If you read the fine print it is scary, and that is only the stuff that they are legally required to tell you. Anything that they are not legally required to tell you will not be there. Do not trust them at all. Do not watch them. They are dangerous.

Although I am going to look at see how Consumer Reports rates the NuWave Bravo…

A "little information" can be dangerous to your health

“A little information can be a dangerous thing.”

I don’t know who first said that; no one seems to. But it is used all the time, and as a physician I both see the impact of that little knowledge on people’s health and the difficulty of striking a balance between providing meaningful information in a form that people can use and oversimplifying to the point of danger. I have worked very hard on honing this skill, and think I do it reasonably well, but I am absolutely certain that I have failed abysmally time and time again. Hopefully, it has not hurt too many people, but who knows?

I have written before that one of my roles, as a friend and family member, is to try to interpret for them what their doctor meant by what s/he told them. Or, more correctly, what my friends and family members think s/he told them. Indeed, a key part of this is trying to figure out what the doctor (presuming they are reasonably competent) might have said that led my friend/relative to think that what they are telling me is what s/he said.

And, just as I make the assumption that these doctors are reasonably competent, I make the assumption that those friends and relatives are reasonably intelligent, or at least not particularly less so than the bulk of the population (side note: I honestly think that, on average they are far more intelligent). This is borne out by the fact that it is not just friends and relatives. From time to time, I overhear conversations between other people about their health. One of the most common places is the locker room at the gym; this is because I am there dressing for long enough to be able to overhear a conversation, and also because, as a retired person, I go in the middle of the day when all the other retired – and, therefore, older, and more likely to have health problems – people are there. Usually the conversation is bi-directional but almost always one of the people is acting as a health consultant to the other, advising based on their personal experience of having had, or having a friend or relative who had, the same thing. Or, and here is where a lot of the danger comes from, something that seems very similar.

[This is the time to review, either via YouTube or its transcription on one of my old blogs, "Eggs Benedict" and "Choosing Wisely": often the best thing to do is nothing, the Woody Allen bit “Eggs Benedict”.]

Things that seem similar may not be the same – or even similar. To a health professional, there is a huge difference between an orthopedist (a bone surgeon) and an orthodontist (a dental specialist who straightens crooked teeth), but to a regular person they sound a lot alike. And it is not only confusion of words; lots of conditions that are very different sound very similar (you know, a lot of diseases end in “-itis”, which just means “inflammation of”). And even conditions that are very similar – or even the same – manifest differently in different people depending upon a lot of personal characteristics (just to name a few: age, sex, weight, co-existing conditions [another term that doctors use all the time that people may not understand], and duration and exact character of symptoms and findings). Lots of stuff is treated differently in its early stages than in its later stages, and often many different treatments are available. Maybe the one the doctor chose for you isn’t the best, and maybe the one you see advertised on TV or the home remedy advised by your aunt will work better. Or maybe not. Maybe, even, there was some scientific rationale behind that choice of treatment.

Which, of course, leads inevitably to a short discussion of direct-to-consumer advertising of drugs, particularly on television. I see these a lot more than I used to, not because I sit around in retirement watching daytime TV but because of the same gym; while I’m on the elliptical I am often unable to choose shows (ones with plots) because someone else has already chosen the program on the group TV, and there are a lot of ads. Many of them for treatments for pretty uncommon diseases. Which is, by the way, a guarantee that they cost a fortune. After all, why advertise on TV, a very expensive proposition, unless you stand to make a lot of money either because a lot of people have the problem your drug treats (e.g., arthritis) or the drug you are selling (clue: anything whose generic name ends in “-ib”, made from recombinant DNA) is so expensive that even a small market will make you a fortune? There is absolutely nothing at all good (and I’ll say that again!) about direct to consumer advertising of drugs on TV (“ask your doctor about whether [incredibly expensive] ‘Blorkamib’ is right for you!”). Except, of course, for the drug company that makes it and advertises it. These ads create unrealistic hope and expectation, create doubt as to whether your doctor is up-to-date on the latest treatments (you know, s/he is busy seeing patients all day so may not see the ads on daytime TV!), and sets you up to expect miracles. (By the way, there are very few of these.) If you must watch such commericials, I suggest you only focus on the fine print possible – often common and very bad – side effects in the small print at the end.

The late, great Hawai’ian singer Israel Kamakawiwo’ole makes a valiant effort on the last cut of his album “IZ” to explain the cause and treatment of the congestive heart failure (along with, and in part caused by, his tremendous obesity) that eventually killed him at the age of 38. It’s a pretty good discussion of the role of oxygen, although it doesn’t quite get it right, but it may have helped some of those who heard it. He had great influence; his recording of “Somewhere over the rainbow” mixes up the lyrics from different verses, but I suspect that for many people, hIZ lyrics are now the ones they know (so if they seem disconnected to you, don’t blame original lyricist Yip Harburg!).

But it is not just singers who have trouble with it; being educated and smart doesn’t make one medically knowledgeable. I know this from treating lawyers, accountants, engineers, English professors, and even medical school faculty in the basic sciences (although the physiologists, unsurprisingly, understand heart failure better than IZ…). It makes it hard to try to convey accurate information, as completely as possible, without losing people’s ability to grok it and without using metaphors that, while intended to help, may unintentionally send folks off to the wrong conclusions. It is important to try, though, and to ask not if people understand (usually they’ll say yes) but what they understood, so you can correct any misinterpretations.

People will probably do what their mother tells them to anyway.