{"id":52094,"date":"2014-12-10T20:26:34","date_gmt":"2014-12-11T01:26:34","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=52094"},"modified":"2014-12-10T20:42:58","modified_gmt":"2014-12-11T01:42:58","slug":"we-were-warned-2","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/12\/10\/we-were-warned-2\/","title":{"rendered":"we were warned…"},"content":{"rendered":"
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The new medical-industrial complex.<\/a><\/div>\n
by Relman AS.<\/div>\n
New England Journal of Medicine<\/font><\/strong>. 1980<\/font><\/strong>  303[17]:963-70.<\/div>\n

<\/p>\n

The most important health-care development of the day is the recent, relatively unheralded rise of a huge new industry that supplies health-care services for profit. Proprietary hospitals and nursing homes, diagnostic laboratories, home-care and emergency-room services, hemodialysis, and a wide variety of other services produced a gross income to this industry last year of about $35 billion to +40 billion. This new "medical-industrial complex" may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and "cream-skimming," and it may also exercise undue influence on national health policy. In this medical market, physicians must act as discerning purchasing agents for their patients and therefore should have no conflicting financial interests. Closer attention from the public and the profession, and careful study, are necessary to ensure that the "medical-industrial complex" puts the interest of the public before those of its stockholders.<\/div>\n<\/blockquote>\n
It’s an old article, a classic, but I couldn’t locate a full text version on the Internet. So I purloined his introduction…<\/div>\n
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…and his concluding thoughts:<\/div>\n
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Dr. Relman got a lot of things right, but if you’ve followed the history of psychiatry since he wrote this in 1980, he got the part highlighted in red<\/font><\/strong> very wrong [about the pharmaceutical and device industries]. I can’t blame him. If I had been asked in 1980, I would’ve said the exact same thing. What actually happened was something of a shock to me. As bizarre as it sounds today, what he has to say wasn’t lost on a lot of us even earlier, and it was a part of why I moved to psychiatry – thinking I might side-step the coming industrialization of medicine [speaking of being dead wrong – so I’m no visionary either]. But the thrust of what Dr. Relman wrote was, indeed, visionary – a tragic vision as it played out. And his comments, highlighted in blue<\/font><\/strong>, are crystal clear – an obvious prescription for salvation that was ignored. Flash forward to now: <\/div>\n
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Drug Makers are Targeting Patients in Physician Offices More Than Ever <\/a><\/div>\n
Pharmalot: WSJ <\/font><\/strong><\/div>\n
by Ed Silverman<\/div>\n
Dec 4, 2014<\/font><\/strong> <\/div>\n

Walk into any physician’s office and promotional messages about medicines can be seen no matter where you look – brochures are typically displayed on a counter and advertorial messages are often playing on a flat-screen TV mounted on a wall. This type of patient outreach, which is called point-of-care marketing, is hardly new, but what is different is that the pharmaceutical industry and other companies selling health products are relying on this form of promotion more than ever before, according to a new study<\/a>.<\/p>\n

Since 2010, the amount of money spent on POC marketing in physician offices, hospitals and pharmacies grew 10% annually, reaching $400 million this year. Nearly 90% of that spending was done by drug makers, says Hensley Evans of ZS Associates, a consulting firm that conducted the study. Moreover, spending on POC is expected to exceed $500 million within the next two to four years. “This is clearly growing in importance,” says Evans, adding that POC communications are second only to television advertising in terms of reaching consumers.<\/p>\n

Of course, patients waiting to see a doctor are the classic captive audience. ZS points to another study that found 89% percent of patients say they watch television in a waiting room, and 76% of patients recalled information they read or heard in a waiting room. Moreover, ZS notes that patients can wait 20 to 40 minutes to see a physician, and wait times are expected to rise over the next decade as the number of visits to primary care doctors reaches 565 million in 2025, up from 462 million in 2008. ZS also cites data indicating 65% of patients find POC materials credible because there is an implied endorsement from the doctor. This is a subtle but important distinction from DTC advertising on television, if only because the consumer receives the message at home or in some other surrounding.<\/p>\n

Meanwhile, the growth in direct-to-consumer advertising for prescription drugs rose 1.3% on a compounded annual basis. As a result, ZS calculates that POC spending will have accounted for 10% of all DTC spending this year, up from slightly less than 7% in 2010. The shift reflects a few developments. For one, drug makers are increasingly trying to remind patients to take their medicine, since adherence boosts revenue. And ZS notes that a logical forum for delivering that message is in a location where diagnosis and treatment are discussed.<\/p>\n

At the same time, drug makers are selling fewer blockbusters to the widest possible patient population and, instead, are increasingly marketing therapies targeted at specific patient groups. This shift calls for more customized marketing than what television commercials may allow, according to ZS. The marketing is apparently having the desired effect. ZS cites data indicating that 84% of patients who visited waiting rooms and were exposed to POC communications report that the messages made them interested in the product.<\/p>\n

Nonetheless, Evans does not believe that POC marketing will overtake or supplant other forms of marketing. Rather, she believes that drug makers are simply increasing their POC spending in response to changing business models. “But we are seeing more consumers become more engaged,” says Evans. “They can have a more educated conversion with physicians and not just about a promoted brand [product], but also about broader information for treating a condition.”<\/p>\n

If this sounds familiar it is because this is the same explanation that the pharmaceutical industry has used to explain why DTC advertising is beneficial. Some doctors, however, complained that patients were not given complete information or were unnecessarily prompted to ask for certain medicines. Now, though, the marketing is increasingly shifting to the physician office. In effect, the physician has become more of a marketing partner with the pharmaceutical industry.<\/div>\n<\/blockquote>\n

In 1980, Dr. Relman saw what had already happened in the years after President Nixon opened Pandora’s Box in 1973 [see «parity?<\/em>»…<\/a>] with the Health Maintenance Organization Act<\/a><\/font>, "which encouraged rapid growth of Health Maintenance Organizations [HMOs], the first form of managed care.<\/font>" While it may seem far-fetched to propose that things could change in so a short period, that’s certainly how it felt. 1980 was actually probably too late. Dr. Relman was the long-time editor of the New England Journal of Medicine<\/font> [see Dr. Arnold Relman, 91, Journal Editor and Health System Critic, Dies<\/a>] who continued the themes in this piece throughout the remainder of his career. I’m not aware of his mentioning psychiatry, but his wife, Marcia Angell, who later also became an editor of the NEJM herself, made up for that in her widely read review of the books of Irving Kirsch [The Emperor’s New Drugs: Exploding the Antidepressant Myth<\/a>], Robert Whitaker [Anatomy of an Epidemic<\/a>], and Danny Carlat [Unhinged: The Trouble with Psychiatry<\/a>] [see in the name of ethics…<\/a> and no leg to stand on…<\/a>].<\/p>\n

\"Pandora\"It’s such an old story – Pandora’s Box. She was given a box [actually, a jar<\/a>] as a wedding present with the injunction to never open it. Pandora’s curiosity won out but in opening the box, she unwittingly unleashed all the evils stored inside to spread throughout the world. So the lesson of the story is that some things, once released, can be neither contained nor put back in the box.<\/em><\/p>\n

In psychiatry, the pen of Richard Nixon wasn’t necessary. In 1974, Mel Sabshin became Director of the APA with the mandate to bring psychiatry firmly into the fold of the rest of medicine, fueled by the neoKraepelinians at Washington University and other centers in the Midwest. Over the 1970s, Dr. Robert Spitzer refined their crude classification [the Feighner Criteria] to produce the widely heralded DSM-III diagnostic manual. In the last post [«parity?<\/em>»…<\/a>], I called it medicalesque<\/em> because it looked medical with [sort of] well defined criteria. But since psychiatry has no disease markers [biomarkers], validity<\/em> was replaced with reliability<\/em> [using the criteria, there was agreement among clinicians]. The background agenda, ending the hegemony of the psychoanalysts in psychiatry was quickly realized. The medicalization<\/em> of psychiatric diagnosis was a surprising public success. Managed Care used it to fix reimbursement by Disorder, and moved psychotherapy out of psychiatry [the non-physician therapists using the DSM-III for billing purposes with their new-found access to insurance payment]. Pharmaceutical companies used the DSM-III for FDA Approval by diagnostic category while detailing<\/em> primary care physicians to prescribe the drugs based on symptoms. By the time of his retirement twenty years later, Dr. Sabshin was writing:<\/div>\n