Chapter 9
Public Opinion About the Health Care System

As with many other social issues, public opinion about health care systems, providers, plans, coverage, and benefits varies in response to a variety of personal, political, and economic forces. Personal experience and the experience of friends, family, and community opinion leaders—trusted sources of information such as members of the clergy, prominent physicians, and local business and civic leaders—exert powerful influences on public opinion. Health care marketing executives have known for years that the most potent advertising any hospital, medical group, or managed care plan can have is not a full-page newspaper advertisement or prime-time television ad campaign. It is positive word-of-mouth publicity.

Political events, the economy, and pending legislation can focus public attention on a particular health care concern, supplant one health-related issue with another, or eclipse health care from public view altogether. In 2005 hurricanes Katrina and Rita focused attention on the U.S. public health and federal emergency management systems' capacities to effectively respond to disasters. At the same time, federal, state, and local government officials assessed disaster preparedness funding and plans for the possibility of an influenza pandemic arising from the H5N1 avian flu that had already swept through birds in parts of Asia and Europe and might arrive in the United States sometime in late 2006 or 2007.

In April 2006 the Gallup Organization found that 6% of Americans named health care—poor hospitals and high costs—as the most pressing problem facing the country. Although 6% may not seem significant, the same percent of survey respondents named terrorism, education, and unemployment as the nation's most pressing problems. (See Figure 9.1.)

Confusion and conflicting opinions about the value to individuals and national cost of the Medicare prescription drug benefit also made the headlines, as did concerns about prescription drug side effects and adverse reactions as the U.S. Food and Drug Administration (FDA) asked an increasing number of drug makers to include stronger safety warnings on their products. The medical literature and lay press debate about the role of antidepressants and other psychotropic drugs used to treat mental illness intensified in June 2005 when Hollywood star Tom Cruise decried their use and criticized actress Brooke Shields for using antidepressants for postpartum depression—an acute mental disorder following childbirth.

The national economy and the rate of increase of health care costs, especially out-of-pocket expenses, also play important roles in shaping public opinion. When unemployment rates are high, the proportion of people without insurance increases, workers fear losing their jobs and their health care coverage, and dissatisfaction with the present health care system grows. Many surveys show a direct relationship between rising out-of-pocket expenses and dissatisfaction with the health care system. The recent spike in health care costs coupled with survey findings that employers intend to pass off some of the increasing costs to their employees will likely inspire renewed interest in health care reform.

An increasing percentage of Americans of all political persuasions are concerned about health care access, availability, and quality. A March 2006 Gallup Poll revealed that more than two-thirds (68%) of Americans were very worried about health care availability and access, up 8% from 2005. (See Table 9.1.) David W. Moore in "Healthcare of Great Concern to Republicans and Democrats Alike" (March 28, 2006, http://poll.gallup.com/content/default.aspx?ci=22069) reports that more Democrats (78%) and Independents (66%) than Republicans (57%) said they worry "a great deal" about health care.

At the close of 2005, slightly more than half of Americans (53%) rated the overall quality of U.S. health care as "good" or "excellent," while 47% said it was just "fair" or "poor." Figure 9.2 shows that the percent that feel positively about the U.S. health care system has declined from a high of 60% in November 2003 and the percent that held negative views of the system increased by 7% during the same period. Favorable opinions about health care coverage in the United States fell to a new low in 2005, with the majority of respondents of all ages and political affiliations expressing dissatisfaction with coverage. More than three-quarters of survey respondents (78%) felt that health care coverage was only "fair" or "poor" and just 21% deemed it "good" or "excellent." (See Figure 9.3.)

In view of this growing dissatisfaction with quality and coverage as well as concerns about access and availability of services, it is not surprising that fewer Americans favor retaining the current health care system—just 49% in November 2005, down 14% from the previous year—while 41%, up 9% from the previous year, think the current system should be replaced by a government-administered health care system. (See Figure 9.4.)

In Table 9.1 survey respondents named health care as the most worrisome problem of the dozen presented by the poll, with concern about Social Security and the afford-ability of energy the second and third most troubling problems, followed by drug use, crime and violence, and the possibility of future terrorist attacks in the United States. When the Gallup Organization asked in "Election 2006" (January 2006, http://poll.gallup.com/content/default.aspx?ci=4534) about the relative importance of a variety of issues likely to influence voters' choices in upcoming congressional elections, 43% of survey respondents said health care was an "extremely important" consideration, and an additional 39% said it was "very important." An April 2006 Gallup Poll asked survey respondents, without prompting, to name the top priority for the president and Congress; health care made the list of the top five priorities Americans would like to see addressed by their government. (See Figure 9.5.)

Demographic changes, particularly the aging of the baby boomer generation (people born between 1943 and

1960) into Medicare eligibility, may also fuel concern and dissatisfaction with the health care system. If the health care futurists who have projected glaring deficiencies in the current system's capacity to meet the needs of the aging population are correct, this generation may become the largest and most vocal advocates for health care reform. A May 2006 Gallup Poll found persisting dissatisfaction with the way President George W. Bush was handling health care policy. Table 9.2 shows that disapproval of the handling of health policy has increased steadily from 37% in March 2002 to 63% in April 2006. Another poll conducted during the same month found that older adults (people over age sixty-five), as well as people of all ages, were critical of the new Medicare prescription drug plan, with more than half (53%) of older respondents opining that it was "not working." (See Table 9.3.)

Finally, the influence of the news media, advertising, and other attempts to sway health care consumers' attitudes and purchasing behaviors cannot be overlooked. A single story about a miraculous medical breakthrough or lifesaving procedure can reflect favorably on an entire hospital or health care delivery system. Similarly, a lone

mistake, adverse reaction to a drug, or a misstep by a single health care practitioner can impugn a hospital, managed care plan, or pharmaceutical company for months or even years, prompting intense media scrutiny of every action taken by the facility or organization.

Some industry observers believe that health care providers, policy makers, biomedical technology and research firms, and academic medical centers have fanned the flames of consumer dissatisfaction with the health care system by "overselling" the promise and the progress of modern medicine and the U.S. health care system. They fear that overzealous promotion of every scientific discovery with a potential clinical application has created unrealistic expectations of modern medicine. Health care consumers who believe there should be "one pill for every ill" or feel that all technology should be made widely available even before its efficacy has been demonstrated are more likely to be dissatisfied with the present health care system.

AMERICANS FEEL THEIR OWN HEALTH CARE IS BETTER THAN THE U.S. HEALTH CARE SYSTEM

Interestingly, most Americans give much higher ratings to the care they receive than to the larger U.S. health care system. A December 2005 Gallup Poll found that more than three-quarters of Americans (78%) felt the quality of care they receive was "excellent" or "good," and over half (53%) gave comparable high ratings to their health care coverage. (See Table 9.4.) Nearly half of survey respondents (47%) said the quality of health care they receive is the same as the quality of care delivered by the U.S. health care system, 44% felt their personal care was better than care provided by the larger system, and only 9% rated the quality

of the U.S. health care system as better than their own personal care. (See Figure 9.6.)

The survey respondents were even more positive about their own health care coverage. Sixty-four percent felt their coverage was superior to U.S. health care coverage in general, 30% said their own coverage was comparable to U.S. health care coverage, and just 6% said their personal coverage compared unfavorably to U.S. health care coverage. (See Figure 9.7.)

Compared with the previous year, fewer respondents rated their insurance coverage as "excellent/good"—63%, down from 69%—and the percentage rating their insurance as only "fair/poor" rose from 27% to 32%. (See Figure 9.8.) The less favorable ratings are directly linked to rising insurance premiums, because the percentage of respondents with private insurance that said they were paying more for their health insurance was unchanged from the previous year. Similarly, the percentage of respondents that was satisfied with their total costs for health care remained constant. (See Table 9.5.)

MANY AMERICANS BELIEVE THAT ACCESS TO HEALTH CARE IS A RIGHT

A February 2006 Gallup Poll reconfirmed that Americans believe that the federal government should ensure that its citizens have health care coverage. Since 2000 more than half of those polled held this opinion, although the most recent poll saw a 6% decline (from 64% in 2004 to 58% in 2005) from the previous year in the percentage expressing this conviction. (See Figure 9.9.)

Interestingly, while Americans want government to provide health care coverage, the Gallup Organization found in "Gallup's Pulse of Democracy: Healthcare Costs" (2006, http://poll.gallup.com/content/default.aspx?ci=4708&pg=1) that they do not favor a national health care plan. Instead, they support measures such as offering tax deductions to employers that provide health care coverage, expanding low-income federal assistance, lowering the age for eligibility for Medicare to fifty-five, tax deductions for the uninsured, and mandating businesses to offer health insurance.

MANY AMERICANS ARE CONCERNED ABOUT THEIR ABILITY TO PAY FOR HEALTH CARE

In view of escalating health care costs and increasing out-of-pocket expenses, it is understandable that Americans are extremely concerned about health care costs. Gallup Organization surveys have repeatedly found that health care costs, which continue to rise much faster than inflation, top the list of health problems Americans believe beset the nation and are perceived as more urgent than threats of specific diseases. Well over three-quarters (79%) of Americans are generally dissatisfied with the cost of health care. (See Table 9.6.) Concern about the cost of care deterred 28% of survey respondents from seeking medical care,

the highest percentage in more than a decade. (See Table 9.7.) Table 9.8 shows that of those who delayed or deferred seeking medical treatment, 18% put off seeking care for a "very serious" medical problem, and an additional 37% said they did not seek timely care for a "somewhat serious" illness or condition.

Even wealthy Americans fear that escalating health care costs will consume their financial assets. In "Health Care Costs and Medicare's Future Pose Huge Threats to U.S. Family Assets, Reports PNC Survey of Wealthy Americans" (January 31, 2006, http://www.prnewswire.com/cgi-bin/micro_stories.pl?ACCT=701257&TICK=PNC&STORY=/www/story/01-23-2006/0004265478&EDATE=Jan+23,+2006), a study commissioned by the PNC Financial Services Group Inc. and conducted in October and November 2005 by Harris Interactive, nearly four in ten wealthy Americans, including one-quarter of adults over age sixty-five, said affording health care for their families was a top financial concern, and one in three (36%) respondents opined that "health care costs will ultimately consume a major portion of my financial assets."

More than half of respondents (52%), who were employed with annual incomes of $150,000 or above and at least $500,000 of assets or retired with at least $1 million of assets, rated "providing for my health and wellness" as their number-one financial concern.

CONSUMER SATISFACTION WITH HEALTH CARE FACILITIES

Despite the problems that continue to plague hospitals, such as shortages of nurses and other key personnel, diminished reimbursement, shorter inpatient lengths of stay, sicker patients, and excessively long waiting times for patients in emergency and other hospital departments, consumer satisfaction with hospital services has remained relatively constant since 2000. Rick Blizzard, in "Patient Satisfaction Stable among Unstable Conditions" (May 18, 2004, http://poll.gallup.com/content/default.aspx?ci=11692), reveals that satisfaction with inpatient hospital care dropped slightly between 2000 and 2001 (from a mean score of 3.51 in 2000 to 3.49 in 2001), yet since 2001 it has improved slightly each year, rising to 3.50 in 2002 and 3.51 in 2003.

Interestingly, patient satisfaction with hospital care was linked to the hospital's success in meeting patients' spiritual and emotional needs. This finding, that satisfaction is associated with intangible qualities of the hospital experience such as sensitivity, attention, and responsiveness to emotional and spiritual needs, underscores the fact that many health care consumers assess the quality of service they receive in terms of the care and compassion displayed by hospital personnel.

In 2005 the Gallup Organization sought to determine whether patient safety initiatives instituted by hospitals in response to the 1999 Institute of Medicine landmark study to reduce the rate of medical errors had actually served to make patients feel safer and more secure. An analysis of the data found that despite well-publicized efforts to implement safety protocols, patient satisfaction with hospital staff efforts to make them feel safe and secure was virtually unchanged from 2001 through 2004. In "Safety, Security Flatline with Patients" (June 28, 2005, http://poll.gallup.com/content/default.aspx?ci=17125&pg=1), Rick Blizzard attributes the absence of improved perceptions of safety to the fact that many of the innovations in information systems and procedural changes were imperceptible to patients. He opines that patient satisfaction and security was more strongly influenced by patients' perceptions that hospital employees were listening to them and cared about them. Blizzard asserts that improved patient-employee communication and relationships would not only prevent errors but also improve patient satisfaction.

Americans Assess Health Care Quality

In "Many U.S. Adults Believe Healthcare Quality Can Be Fairly Assessed, but Few Willing to Pay Significantly Higher Premiums for Superior Care" (April 4, 2006, http://www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=1038), a Wall Street Journal-Harris Interactive survey, about half of Americans (49%) think there are reliable ways to assess the quality of hospitals, physicians, and other health care providers. More than two-thirds (69%) cited the results of patient satisfaction surveys as measures of quality, 61% felt that tests that measure how physicians handle chronic medical problems help to evaluate quality, 57% relied on assessments performed by independent quality assurance organizations, and 55% considered the frequency of preventive medicine screening tests a dependable indicator of quality. Less than half of the survey respondents thought that electronic medical records (47%) and malpractice suits (41%) were reasonable measures of quality.

While the survey respondents felt it was good to assess quality, they were uncertain whether health care provider compensation should be tied to performance. Just 19% of respondents believed it would be fair to pay hospitals and physicians more because they provided better care as measured by a set of quality indicators. Even fewer (14%) said they would be willing to pay more for medical care from providers who have demonstrated quality, and more than half (55%) of respondents said they were unwilling to pay higher premiums to receive care from top-rated hospitals or medical groups.

PATIENTS' RATINGS OF THEIR CARE ARE NOT ASSOCIATED WITH TECHNICAL QUALITY OF CARE

When John T. Chang et al. sought to determine whether patients' ratings of their health care were consistent with independent assessments of the technical quality of care delivered, they find in "Patients' Global Ratings of Their Health Care Are Not Associated with the Technical Quality of Their Care" (Annals of Internal Medicine, May 2, 2006) that favorable patient ratings were not associated with the technical quality of the care provided. Instead, as previous studies reported, patients gave high ratings to physicians with strong interpersonal and communications skills. Chang et al. find that patients who rated overall quality as poor were also likely to rate communication with their health providers as poor and that patients who rated their care as very good may actually have received poor care based on a review of their medical records. As a result, Chang et al. conclude that assessments of quality should include both patients' perceptions of quality and objective, independent assessments of the degree to which care and treatment are consistent with established standards of care.

EMPLOYER-SPONSORED HEALTH PLANS

The Employer Health Benefits 2005 Annual Survey (2006, http://www.kff.org/insurance/7315/upload/7315.pdf), conducted since 1999 by the Henry J. Kaiser Family Foundation and the Health Research and Educational Trust, finds that the rate at which health insurance premiums rose declined for the second year, to 9.2% in 2005. The survey finds that in 2005 just 60% of all firms offered health coverage to their workers, down 9% in five years. The decision to offer health benefits varied by company size—nearly all firms with fifty or more workers offered health benefits, and the declining rate of firms offering benefits was largely attributable to a drop in the percentage of small businesses (three to 199 workers) offering coverage, from 68% in 2000 to 59% in 2005.

In 2005 benefits were offered by 87% of firms with twenty-five to forty-nine employees, 72% of firms with ten to twenty-four workers, and 47% of companies with three to nine employees. More than 90% of companies that employ union workers offer health benefits.

The survey reveals that as employers try to rein in the rising cost of health insurance, the vast majority of workers paid for premiums and encountered substantial cost sharing (deductibles, coinsurance, and co-payments) for services such as office visits, prescription drugs, and hospital admissions. Nearly four in five workers paid a deductible before health care expenses were covered by their plans. More than two in five employees paid a separate deductible, co-payment, or coinsurance for admission to a hospital, and almost all workers paid a co-payment or coinsurance for physician office visits. One-fifth of firms that provided coverage offered high-deductible health plans (for the purpose of this survey, high-deductible health plans were defined as having a deductible of $1,000 for an individual and $2,000 for family coverage). Most workers were also in plans with cost-sharing arrangements for prescription drugs.

SATISFACTION WITH HIGH-DEDUCTIBLE AND CONSUMER-DRIVEN HEALTH PLANS

As reported by Paul Fronstin and Sara R. Collins in "Early Experience with High-Deductible and Consumer-Driven Health Plans: Findings from the EBRI/Common-wealth Fund Consumerism in Health Care Survey" (December 2005, http://papers.ssrn.com/sol3/papers.cfm?abstract_id=870483), the Consumerism in Health Care Survey, which was conducted by the Employee Benefit Research Institute and the Commonwealth Fund, reveals that nearly two-thirds of people enrolled in the most comprehensive traditional health plans (63%) were satisfied with their plans, considerably more than those with high-deductible plans (33%), or people in consumer-driven health plans (42%). (For the purposes of this study, consumer-driven health plans were health savings accounts and health reimbursement arrangements, and high-deductible plans were those with deductibles of $1,000 or more for individual plans and $2,000 or more for family plans.) Well over half (60%) of those with comprehensive insurance said they were extremely or very likely to remain with their current health plan, compared to just 30% of those in high-deductible plans and 46% of people in consumer-driven health plans.

Not surprisingly, the survey finds that people with consumer-driven and high-deductible plans were much more likely to spend a large share of their income on out-of-pocket health care expenses than those in comprehensive health plans. Two-fifths (42%) of those in high-deductible plans and 31% percent of those in consumer-driven health plans spent 5% or more of their income on out-of-pocket costs and premiums in the last year, compared with 12% of people enrolled in comprehensive health plans.

Furthermore, people in comprehensive plans were much less likely to report skipping, delaying, or deferring medical care than those in consumer-driven or high-deductible plans (17%, compared with 35% and 31%, respectively). The survey also finds that people in consumer-driven and high-deductible plans were more likely than those in comprehensive plans to consider costs when choosing providers and more likely to discuss the costs of treatment with their health care providers.

A GROWING NUMBER LOOK FOR HEALTH INFORMATION ONLINE

Although public trust in hospitals and personal physicians remains relatively high, and many people seek and receive health education from physicians, nurses, and other health professionals, a growing number of Americans are seeking health information online. Harris Poll researchers dub the more than 117 million adults who seek information about specific diseases or tips about how to maintain health on the Internet "cyberch-ondriacs."

Researchers report in "Number of 'Cyberchon-driacs'—U.S. Adults Who Go Online for Health Information—Increases to Estimated 117 Million" (July 15, 2005, http://www.harrisinteractive.com/harris_poll/index.asp?PID=584), a Harris Interactive nationwide survey about the use of the Internet to find health information online, that nearly three-quarters of American adults (74%) sought health information online. Typically, cyberchondriacs searched the Internet for health information about seven times per month, up from five times per month just one year ago and three times per month in 2001. The vast majority of cyberchondriacs (89%) said they found the information they were seeking on the Internet.

The 2005 Harris Poll found that 57% of cyberchondriacs used the Internet to become better informed about health matters and often discussed the results of their searches for information with their physicians. More than half (52%) reported using the Internet to obtain information following discussions with their physicians.

MARKETING PRESCRIPTION DRUGS TO CONSUMERS

Although health care consumers continue to receive much of their information from physicians, nurses, other health professionals, and the Internet, many also learn about health care services and products from reports in the news media and from advertising. Media advertising—promotion of hospitals, health insurance, managed care plans, medical groups, and related health services and products—has been a mainstay of health care marketing efforts since the 1970s. During the early 1990s pharmaceutical companies made their first forays into advertising of prescription drugs directly to consumers. Before the 1990s pharmaceutical companies' promotion efforts had focused almost exclusively on physicians, the health professionals who prescribe their products.

Since the mid-1990s spending on prescription drugs has escalated and has become the fastest-growing segment of U.S. health care expenditures. In 1997 the FDA released guidelines governing direct-to-consumer advertising and seemingly opened a floodgate of print, radio, and television advertisements promoting prescription drugs. Industry observers wondered if this upsurge of direct-to-consumer advertising had resulted in more, and possibly inappropriate, prescribing and higher costs.

Is Direct-to-Consumer Advertising Effective?

It stands to reason that pharmaceutical companies must be receiving significant returns on their direct-to-consumer advertising investments to justify increasing budgets for consumer advertising, but it is difficult to measure the precise impact of consumer advertising on drug sales. Meredith B. Rosenthal et al., in "Promotion of Prescription Drugs to Consumers: A Look at the Numbers" (New England Journal of Medicine, February 14, 2002), find that spending on direct-to-consumer advertising for prescription drugs tripled between 1996 and 2000, when it reached nearly $2.5 billion. In "Drugmakers Not Asleep When It Comes to Advertising" (June 2, 2006, http://www.philly.com/mld/philly/business/14720111.htm), Rob Waters notes that spending on direct-to-consumer prescription drug advertising increased by 7% to $4.8 billion in 2005, even though the pharmaceutical industry agreed to adhere to Pharmaceutical Research and Manufacturers of America guidelines urging the inclusion of information about the risks as well as the benefits of the drugs in direct-to-consumer advertising.

Mollyann Brodie evaluated consumers' reactions to drug ads by showing research participants actual prescription drug ads and recording their responses. In Understanding the Effects of Direct-to-Consumer Prescription Drug Advertising (November 2001, http://www.kff.org/rxdrugs/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13706), Brodie reports that one in three adults said they talked with their doctor after seeing an ad for a prescription drug and nearly half of those who spoke with their physicians about the drug (44%) received a prescription for that drug. Brodie also finds that two-thirds of consumers who viewed prescription drug ads trusted the information they received in the ads, and 84% said the ads did an excellent or good job informing them about the condition that the advertised drug was intended to treat. Despite the ad viewers' perception that they were well informed, Brodie finds that recall about potential drug side effects and viewer knowledge about where they could find more information about the advertised medication varied widely. In view of the speed with which some television drug ads announce potential side effects and adverse reactions, it was not surprising that as many as 75% of viewers could not accurately identify many of the advertised drug's side effects.

Reporting on a nationwide survey of adults conducted by Harris Interactive between July 2001 and January 2002, Humphrey Taylor and Robert Leitman, in "The Impact of Direct-to-Consumer Advertising of Prescription Drugs on Consumer Behavior, Diagnosis and Treatment" (June 23, 2003, http://www.harrisinteractive.com/news/newsletters/healthnews/HI_HealthCareNews2003Vol3_Iss11.pdf), note that the survey reconfirmed the marketing impact of direct-to-consumer advertising. The overwhelming majority of survey respondents (86%) recalled seeing or hearing the direct-to-consumer advertising of prescription drugs, and more than one-third (35%) discussed an advertised drug with a physician. Furthermore, the survey aimed to determine the specific conditions that were diagnosed as a result of physician visits prompted by direct-to-consumer advertising, the actions taken during such visits, and the outcomes that resulted from taking prescription medication prescribed during these visits.

Taylor and Leitman find that at one-quarter of the physician visits prompted by advertising, the physician diagnosed new conditions—identifying previously undiagnosed conditions. The most common new diagnoses were allergies, gastroesophageal reflux disease, high cholesterol, arthritis, hypertension, diabetes, depression, anxiety, heartburn, heart disease, and the effects of menopause. Nearly three-quarters of physician visits prompted by advertising resulted in a prescription being written, and in 43% of visits the prescription was for the drug the patient had seen advertised.

The majority (81%) of patients who received prescriptions at their advertising-induced physician visits reported overall improvement in their health. Interestingly, patients who were prescribed the advertised drug were more likely to report favorable health outcomes than those who received prescriptions for drugs other than the advertised drug.

Is Direct-to-Consumer Advertising of Psychoactive Drugs Helpful or Harmful?

At what point does an understandable response to distressing life events become an indication for drug treatment—and a market opportunity?

—Barbara Mintzes, a University of British Columbia health policy researcher

In Mental Health: A Report of the Surgeon General (1999, http://www.surgeongeneral.gov/library/mentalhealth/home.html), the U.S. surgeon general estimates that about 20% of Americans experience mental health problems and that nearly half of all Americans with severe mental illness do not seek treatment, often because they fear the social stigma and potential loss of employment or health insurance that a diagnosis of mental illness might precipitate. Gallup Organization research confirmed that a substantial percentage of Americans are routinely affected by mental health problems, and 15% described their mental health as "only fair" or "poor." (See Figure 9.10.) Joseph Carroll reports in "Most Americans in Good Mental Health" (January 3, 2006, http://poll.gallup.com/content/default.aspx?ci=20698) that while Americans experienced poor mental or emotional health an average of three days during the month preceding the survey, poor mental health restricted their activities of daily living on just one occasion during the month preceding the survey.

Although these studies rely primarily on self-report, they do suggest that the United States is in the throes of an epidemic of mental illness. Some researchers, however, argue that Americans' mental health is no worse than it was in past decades. They contend that the availability and aggressive marketing of psychopharmacological agents—prescription drugs aimed at mental health problems such as nervousness, anxiety, panic, and shyness—has prompted overdiagnosis of mental health problems and conditions motivated primarily by the desire to increase drug sales.

There have been advocates and opponents of direct-to-consumer prescription drug advertising since its inception. Joel S. Weissman et al., in "Consumers' Reports on the Health Effects of Direct-to-Consumer Drug Advertising" (February 26, 2003, http://www.npcnow.org/resources/PDFs/W3-82Weissman.pdf), find that 35% of respondents discussed an advertised drug with their physicians as a result of direct-to-consumer advertising, a finding that supports the contention that advertising exerts a significant influence on consumer preferences and behavior. Among patients prompted by consumer drug advertising to discuss a health problem with their physicians, one-quarter received a new diagnosis and a new prescription. About four out of five patients who received a prescription drug and took it as prescribed reported that they felt "much better" or "somewhat better" overall after taking the prescription medication. These findings were interpreted as supporting the premise that direct-to-consumer drug advertising increases awareness of specific health problems, provides reliable information, and encourages affected individuals to seek treatment.

Opponents usually contend that direct-to-consumer advertising is primarily intended to drive sales and that it:

• Increases prescription drug costs
• Does not provide the impartial, objective information that would enable consumers to make informed health choices
• Increases risk because, unlike other consumer goods, prescription drugs, even when administered properly, may cause serious adverse reactions
• Takes unfair advantage of vulnerable people facing difficult treatment choices, especially people who suffer from mental illness
• Aims to increase awareness and utilization of newer products to gain market share and recoup development costs (new drugs are not necessarily safer or more effective but are usually costlier, and often little is known about long-term risks)
• Does not enhance consumer awareness or public health because there is no evidence that advertising helps patients to make better choices about prescription drug use
• May unduly influence physician-prescribing practices; physicians often rely on manufacturers for information about drugs, rather than on independent sources, and many studies show that the physicians most influenced by pharmaceutical advertising tend to prescribe less judiciously

In the article "High Anxiety" (Globe and Mail, September 20, 2003), Anne McIlroy asserts that "nervousness, panic and shyness are now part of the most-diagnosed group of mental illnesses—and drug companies just happen to have an array of products to treat them." McIlroy observes that twenty years ago social anxiety was a new and rare mental illness, characterized by debilitating shyness and fear of public humiliation. Today, social anxiety is considered the third most frequently occurring mental health problem in the world and one of half-a-dozen anxiety disorders that are the most frequently diagnosed mental illnesses.

McIlroy opines that depression was the fashionable disease of the 1990s and that anxiety is the disease in vogue during the first decade of the twenty-first century, but she does not think that there has been a surge of anxiety disorders or that anxiety disorders constitute a "hidden epidemic." Instead, she believes that marketing has played a role in the rise of social anxiety and other anxiety disorders and worries that antidepressants such as Paxil, Prozac, Zoloft, and Celexa have been "repur-posed" by their manufacturers as antianxiety drugs to penetrate a new market and reap additional profits. McIlroy also fears that some pharmaceutical marketing blurs the distinction between normal levels of anxiety and pathological anxiety in an effort to "medicalize" normal human conditions and convince consumers that nearly all anxiety is evidence of mental disorders that may be readily resolved with prescription medication.

Other skeptics agree with McIlroy's assertion that drug companies market mental illness as well as its treatment. In 1999, after GlaxoSmithKline received FDA approval to market Paxil for social-anxiety disorder, the company engaged a public-relations firm, which created the slogan "Imagine Being Allergic to People." The advertising campaign did not include the drug company name; instead, it directed consumers to contact the Social Anxiety Disorder Coalition, a drug industry-funded group. In 2001 Paxil was approved for yet another anxiety disorder—generalized anxiety disorder (excessive worrying)—and the drug company's public-relations firm promoted what was formerly considered a problematic personality trait as another disorder that could be effectively treated with Paxil. The campaigns were extremely successful; during the first quarter of 2002 Paxil sales in the United States rose by 25%.

Richard L. Kravitz et al. contend in "Influence of Patients' Requests for Direct-to-Consumer Advertised Antidepressants: A Randomized Controlled Trial" (Journal of the American Medical Association, April 27, 2005) that the consequence of direct-to-consumer advertising is that the medicines that generate profits for drug companies are often overprescribed. During 2003 and 2004 Kravitz et al. sent actors posing as patients to the offices of 152 family physicians and internists practicing in California and New York. The actors scheduled appointments with the physicians during which some described symptoms of major depression, a long-lasting mood disorder often treated with antidepressant medications. Others complained of symptoms of a less serious mental health problem, called adjustment disorder with depressed mood. This condition generally disappears within months without medication.

When the actors posing as patients describing symptoms of major depression did not specifically request an antidepressant, 31% were prescribed medication. Other actors posing as patients told the physicians that a television show about depression had prompted them to seek drug treatment, and in this group 76% received a prescription.

In both groups about 6% of the actors posing as patients who received a prescription were given a prescription for paroxetine (Paxil)—one of several drugs often used to treat major depression. When a third group of actors posing as patients described identical symptoms and asked specifically for Paxil, saying that they had seen an advertisement for it on television, more than half were prescribed the drug they requested.

Among the actors posing as patients who presented with symptoms of adjustment disorder and did not mention antidepressant drugs, just one in ten received a prescription for any medication. However, when the actors asked for medication, nearly 50% were given prescriptions. Most who specifically requested Paxil received a prescription for that drug, while those who simply asked for some sort of medication were prescribed another anti-depressant. Kravitz et al. conclude that "patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse."

Finally, critics of direct-to-consumer advertising, such as Elizabeth A. Almasi et al. in "What Are the Public Health Effects of Direct-to-Consumer Drug Advertising?" (PLOS Medicine, March 1, 2006), contend that the information in these advertisements is frequently biased and misleading and that direct-to-consumer advertising increases prescribing costs and has not demonstrated any evidence of health benefits. They also worry that the emphasis on advertisements for new drugs overshadows other vital public health messages about diet, exercise, addictions, social involvement, equity, pollution, climate change, and appropriate use of older drugs.

Still, many mental health professionals favor direct-to-consumer advertising, crediting it with informing consumers that there is effective treatment for potentially debilitating mental disorders and helping them to overcome reluctance to seek needed treatment. McIlroy notes that Jaques Bradwejn, the chief of psychiatry at the Royal Ottawa Hospital, believes that anxiety disorders remain underdiagnosed and claims he has never had a patient ask to be treated for an anxiety disorder who was not suffering from one.

In Joel S. Weissman et al.'s "Physicians Report on Patient Encounters Involving Direct-to-Consumer Advertising" (Health Affairs, April 28, 2004), a survey of more than 640 U.S. physicians, many physicians opined that pharmaceutical ads were a mixed blessing, simultaneously enhancing patient-physician communication and prompting patients to seek unnecessary treatment. Four-fifths of the survey respondents said that direct-to-consumer advertising not only encourages patients to seek unnecessary treatments but also fails to fully convey the risks and potential adverse effects of drug treatment. Nearly three-quarters of the physicians surveyed said that they thought that direct-to-consumer ads inform people about medicines that might help them, and two-thirds of the doctors said that ads stimulate dialogue. The physicians estimated that one-quarter of the ad-initiated patient-physician conversations lead to diagnoses of treatable problems that might have gone undetected.

Physicians Are Concerned about Drug Safety

As reported by Reuters in "70 Pct of Docs More Worried about Drug Safety: Survey" (May 17, 2006, http://today.reuters.com/news/articleinvesting.aspx?view=CN&symbol=MHS.N&storyid=51938+18-May-2006+RTRS&type=qcna), a 2005 survey of physicians and consumers conducted by Forrester Research for Medco Health Solutions, Inc., a major pharmacy benefits management company, 70% of physicians were concerned about the safety of the drugs they prescribe following safety scares involving several prescription drugs and the media attention surrounding the withdrawal of Vioxx, an arthritis drug, from the market. The same percentage of physicians surveyed said they would prefer prescribing drugs that had been on the market for at least a decade, presumably because the safety and efficacy of these drugs would be better known than for newer entries to the market. One-third of those surveyed felt that newer drugs or those more recently granted FDA approval would likely be less safe than drugs marketed for ten years or longer.

In addition, one-fifth of the survey respondents opined that generic drugs were less safe than their brand-name counterparts, and 27% said they thought generic drugs were more likely to produce adverse side effects than brand-name medications. Medco chief medical officer Robert Epstein asserted that these findings were evidence of the need for intensified efforts to educate physicians about the safety and efficacy of generic drugs.