On the New York Times Health and Medical Coverage

The New York Times Reader: Health and Medicine

The week before last I attended a book launch party for Tom Linden, MD, director of the University of North Carolina’s health journalism program and author of The New York Times Reader on Health and Medicine (CQ Press). Linden has also been a contributing journalist with CNBC and Lifetime Medical Television (I believe I first met him more than 25 years ago when I represented Lifetime). Thanks to my pal and colleague Merrill Rose for inviting me.

For those of us interested in the nexus of medical sciences and journalism, this book should float to the top of the gotta have list. It links some of The Times best articles on medicine with analysis of what goes into journalism and interviews with some of The Times primo science reporters, including Dr. Larry Altman, Gina Kolata and Tara Parker Pope.

Lately I have been thinking how rickety is the same-old same-old approach to public relations: jimmy up that inverted pyramid press release (properly de-souled by the legal and regulatory exorcists), spay it out to the “mass media” and hope for the best. Or calling said mass media and pleading for coverage.

The Times writers, speaking through Linden, talk in detail how their articles are inspired, nurtured and created, using many sources of inspiration and sources of facts and opinion. It’s not that public relations folks cannot help created news articles, but the press release is not often the calling card. Instead it’s individualized pitching providing unique, new and perhaps counter-intuitive angles.

Several of the articles reprinted take to task the pharmaceutical industry for promoting off-label drug use (and yes, we have been guilty of this) and cooking studies or finding (again, it’s been known to happen). But only rarely in this good book has Linden or the reporters he interviewed cast a mirror on themselves by suggesting that they too may have personal biases that they must control like personal demons.

He cites Alex Berenson’s 2006 article on Eli Lilly’s alleged off-label promotion of Zyprexa for dementia, which led ultimately to a $1.42 billion fine. The article was illuminating and a great instrument of journalism; but his sources included plaintiff attorneys that had their own axes to grind. Not pointed out by Berenson.

Hats off however to Tara Parker Pope who admits that it’s not just Big Pharma that reporters should be skeptical of: “…we automatically assume a layer of skepticism about anything that is funded by the pharmaceutical industry. Yet we don’t apply that layer of skepticism to research that is funded by the government, by NIH. There’s always an agenda with every piece of research.”

While every reporter seeks that “great quote” that neatly summarizes a developing story, sometimes a second look is prudent, especially in medical reporting. Gina Kolata famously reported a dinner-party remark by James Watson that Judah Folkman “was going to cure cancer.” On reflection, she admits that she should have called him the day after to reconfim the quote. Yes he said it over din-din, but that doesn’t mean that it exactly expresses his sober judgment.

I worry that great medical journalism is in peril—at the signing party Dr. Altman told me he’s taken The Times buy-out and will only occasionally contribute to the great newspaper. As curmudgeonly as he is, we need guys like him, and books like Linden’s to put it all in perspective.

# # #

Adventure.

Many, many years ago I was traveling with some friends through the interior of what was then Yugoslavia. Looking at the map, it seemed we had two ways to get to Dubrovnik on the coast: a four-lane Tito-age highway and a winding path through the mountains. My British pal said, "let's take the hillier road. It should be a spot of adventure." It turned out to be treacherous; in fact, and this is no lie, we enlisted a donkey to haul our car up one dreadful slope. But we got there and the scenery along the way was breathtaking.

What does this have to do with the here and now?

After 16 months as the itinerant public relations gun for hire, or pharma-hand, I am taking a full-time position as U.S. managing director of Resolute Communications, a UK-based medical education and public relations that is expanding its footprint on this side of the Atlantic. Another spot of adventure.

Is this a great time for health care public relations agencies? No and yes.

No, in the context of clients now guarding every dime, demanding ironclad accountability while at the same time looking over their shoulders, wondering if their jobs are on the Grim Reaper’s to-do list. Many legacy agencies, the sort of organizations I’ve worked for most of my career, seem to be struggling to either redefine themselves, (sometimes with disastrous results), or to prove that their bag of tricks is still exactly what clients need. That bag is full of holes, as the challenges biopharm companies face are changing and the tried-and-true tactics are now tried and tired.

But it’s also a wonderful time for health care practices, IF they can demonstrate relevance, if they can show value for the bucks, Euros or yen invested and if they can convince clients that they can give them first-class thoughtful counsel at an affordable price.

Health reform—which President Obama et al. resuscitated like a contemporary Lazarus—will put a premium on disease awareness and health promotion activities; jobs exactly suited for public relations agencies.

The debate about what sort of agencies will flourish in the future—large companies with massive resources or small companies wedded to personalized attention is irrelevant. Big companies can thrive, as can small agencies; the key is their ability to continually adapt to the marketplace and convince clients that public relations strategies can influence consumer behavior in a way that will benefit their brands. Over the past year + I have had met many people who get this. Paul, Donna, Eve and Laura, to name a few (without really naming anyone). I have also met people who don’t get this.

I joined Resolute because I believe its founders understand the need for relevance in an environment where “show me” is essential. Resolute wants to make medical communications more than the sum of its parts and to me, that’s as it should be. This should be an exciting “spot of adventure” for me. Stay tuned.

Thinking Small: Health Care Micro-Trends

I have an article in the current issue of Communique magazine about micro-trends in health care that may impact our business. Here’s an abridged version of it (the entire article can be found at http://www.communiquelive.com/)

---------------------------------------------------------------------

Mark Penn may not have been all that helpful to Hillary Clinton last year, but he did make a powerful contribution our understanding of societal trends with his book (authored with E. Kinney Zalesne), Microtrends—the Small Forces Behind Tomorrow’s Big Changes.

“Microtrends,” he writes, “is based on the idea that the most powerful forces in our society are the emerging, counterintuitive trends that are shaping tomorrow right before us.” He postulates that less than one percent of the American population—3 million people—is enough to set in motion a trend or support a new business.

Those in the health care marketing community are accustomed to worrying about the large forces that have tsunami-like impact on our business. The impact of genomics, digital media and the aging of the population are all-important but easy marks. But lurking below the big waves have always been modest-sized currents that have had lasting and profound effects on health marketing.

Here are five small trends in health care that may rattle the marketplace in the future. I am sure there are others, and would love your feedback about what they are.

1. Home, Sweet Medical Home
An intriguing step towards reducing health costs while improving patient care is the “patient-centered medical home” concept.

A tiny, but influential group of physicians and their patients are opting for this new model of health delivery, in which a primary care physician is paid to coordinate the total care of his or her patients, usually patients with chronic medical conditions. The patient’s medical needs—from preventive medicine to specialist care to nutrition counseling—are coordinated by this single physician who is armed with both high-voltage information technology and a cadre of specialists to whom to refer the patient if necessary.

The medical home doctor’s mission is to preserve and enhance health, not simply to treat diseases. He or she is paid a modest fee for coordinating services and may receive a bonus if the patient’s health improves.

Already the concept is demonstrating its bona fides. In the Pacific Northwest, a study of 9,200 patients using the medical home approach showed a 29 percent reduction in emergency room visits and an 11 percent decrease in hospitalizations compared with a matched control group.

“By employing technology such as e-mail and mobile phones, physicians in the medical home were able to provide better care that included screening tests, management of chronic illnesses and monitoring of medications. These methods also helped physicians ease the workload – 10 percent of medical home doctors and staff felt “burnt out” or emotionally exhausted, as opposed to 30 percent reported from the control group,” reported Healthcare Finance News.

2. The Proud and Portly
The battle to reduce obesity-related illness has taken many forms, from the popularity of low-fat diets to punitive measures such as proposed taxes on soft drinks and higher insurance premiums for overweight individuals. An executive of one health clinic said that given his preferences, he would simply not hire fat people.

Paralleling the war on weight is a movement declaring fat isn’t the devil’s brew.

There are really two separate movements. The first is comprised of the fatalists or nihilists, who may know the risks of obesity, but believe there is nothing they can do to alter their destructive behavior. They are wrong and are playing Russian roulette with their health.

But a vocal and I believe growing subset of individuals is rallying against the shibboleth that thin equals healthy and happy. The New York Times reported recently “Heavier Americans are pushing back now with newfound vigor in the policy debate, lobbying legislators and trying to move public opinion to recognize their point of view: that thin does not necessarily equal fit, and that people can be happy at any size.”

3. Eaters and Self-Treaters
Drugs to ward off health calamities such as stroke and heart attack continue to sell briskly. While prescriptions for these products will continue to increase, in the future we will also see increase sales of food products with substantiated health claims.

Health claims for foods are not necessarily over-inflated or dubious, such as the claims of some dietary supplements. Multiple studies have shown that plant sterols, for instance, when used in combination with statins, are effective in lowering cholesterol by up 17 percent, which is greater than the average five percent benefit seen by doubling a dose of statin. The value of Omega-3 fatty acids in reducing cardiovascular disease and depression has also been confirmed.

Increased drug costs and headlines about under-appreciated safety risks with conventional medications will likely drive some towards “food remedies,” especially when there is compelling evidence that they can be helpful.


4. Welcome to Medicare
While “managed markets” interests the press and policy marketers, most baby boomers, especially middle and upper middle class professionals, are content with the tried and true private fee-for-service model. It is not unusual for an individual to have been treated by the same doctor for 20 or more years. This arrangement has been the gold standard of American medicine and has been responsible for creating the strong bonds between individual doctors and the patients for generations.

But as boomers approach that magical number “65,” will the relationship between the private physicians and the patient change? Will the doctor even be able to keep Mr. Jones, once his private insurance terminates and he enters the land of Medicare?

5. The Old Old
We recognize that our population is aging, however, it is the “old old”, individuals aged over 85 who are gaining market share faster than any other segment of the population. In 2005 there were 5.1 million individuals older than 85 that number is expected to increase to 7.3 million by 2020 and by 2050 will swell again to 21 million, nearly 5 percent of the American population.

As one can imagine, there are substantive and complicated differences between simply older people and the oldest of the old. Depression, for instance, which is the most common mental disorder among the elders, occurs in between 10 percent and 38 percent of the older population though according to The Journal of Allied Health, diagnosis rates are far lower than the actual incidence of the condition. Depression linearly increases with age, as do other diseases such as macular degeneration, Alzheimer’s disease and heart failure.

Fish on the Beach

I was in London this week—the reasons perhaps I will get into in a future post.

One aspect of British health care public relations that I find interesting is how British PR managers have included medical education in their overall offering. In fact, many UK health care practices make more quid on med ed than on traditional health communications.

Fifteen or twenty years ago, public relations firms on this side of the Atlantic had the opportunity to acquire the largely independent, modest-sized organizations that strategized physician messaging and developed and conducted symposia for physicians and medical congresses and supply continuing education programs as supplements in medical journals.

PR fumbled however and most companies never seriously got into the medical education business. Perhaps agencies were too busy counting the bucks showered on them after they were acquired by the large advertising holding companies. Medical education businesses instead were purchased by medical advertising agencies (that in turn were gobbled up by the holding companies).

Flash forward. Medical advertising agencies are now required to either spin off their med education operations or erect mile-high walls separating them from the more commercial side of the business. Fair enough. It really is in everyone’s best interests to keep physician education—which is supposed to be dispassionate and objective—from advertising which is, well, less objective. Many activists, including prominent doctors, are calling for even higher barriers, effectively precluding pharmaceutical companies from sponsoring any medical education activities; which would leave the medical education firms flopping around like beached fish. Not a good scenario for many reasons.

Here’s why this might be important to public relations: one of the most important product communications strategies is to create educational campaigns to help “raise awareness of xyz-itis as a serious medical condition” and to encourage patients to ask their health care professional if they may be at risk for heartbreak of xyz-itis.

Will there be a point at which the critics of commercial medical education might rear-up and say, whoa, commercial public relations firms should not be undertaking public education campaigns, because the firms may be surreptitiously injecting brand messages into campaigns?

Years ago when I was consulting with Searle for an investigational anti-platelet drug we were proscribed from working with the National Heart, Lung, and Blood Institute because Searle wanted to separate the commercial PR (that’s me!) from health education. Was the late, great head of its time?

While there haven’t been many examples since of companies segregating public education from marketing PR, they might do so in the future. As with medical education, will public relationship firms be forced to cleave off public education into separate stand-alone divisions? That would not harm large firms, but be confounding for smaller public relations agencies.

So far, no one is demanding this separation of church and state, but don’t bet the farm that things will always stay the same.

# # #

Last week Newt Gingrich and John C. Goodman, two fulsome but thoughtful conservatives wrote an op/ed in The Wall Street Journal, “Ten GOP Health Ideas for Obama."

Hats off. They offer serious and helpful recommendations—ideas that could be bandied about at the President’s health care summit next week. But even their good ideas are at best half a loaf in the face of America’s health care famine and if they are serious (and if Democrats are), they should re-tool their recommendations to make them more in line with reality.

Here are their proposals (ripped from The Journal, with my invaluable editing) and my comments. Love to know what you think.

• Make insurance affordable (Gingrich and Goodman say).” The current taxation of health insurance is arbitrary and unfair, giving lavish subsidies to some, like those who get Cadillac coverage from their employers, and almost no relief to people who have to buy their own… A step in the right direction would be to give Americans the choice of a generous tax credit or the ability to deduct the value of their health insurance up to a certain amount.”

The Democrats made a similar point and that’s why some are eager to tax so-called Cadillac health care plans. But Gingrich’s and Goodman’s proposal offers little to those without any health care insurance or low-income Americans.


• Make health insurance portable… “Employers should be encouraged to provide employees with insurance that travels with them from job to job and in and out of the labor market. Also, individuals should have the ability to purchase health insurance across state lines. When insurers compete for consumers, prices will fall and quality will improve.”

I don’t know how or why employers would offer insurance that workers can take with them after they leave a job. And government “encouragement” smacks of the regulations conservatives loath. GOPers talk endlessly about purchasing insurance across state lines. That’s not a bad idea but someone has to regulate these policies and as I’ve said, conservatives want less, not more regulation.

• Meet the needs of the chronically ill. “Most individuals with chronic diseases want to be in charge of their own care. The mother of an asthmatic child, for example, should have a device at home that measures the child's peak airflow and should be taught when to change his medication, rather than going to the doctor each time.”

Good for Newt here; he and Goodman are on to something. But they must acknowledge that patient and family education is costly and will add another digit to the federal health care tab. It’s not wrong, it’s just expensive.

“…Having the ability to obtain and manage more health dollars in Health Savings Accounts is a start.”

Liberals say that health saving accounts benefit mainly the well to-do. But with a commitment to educating consumers, encouraging health savings is a good idea.

• Allow doctors and patients to control costs. “…Medicare pays by task—there is a list of about 7,500—but doctors do not get paid to advise patients on how to lower their drug costs or how to comparison-shop on the Web. In short, they get paid when people are sick, not to keep them healthy. So long as total cost to the government does not rise and quality of care does not suffer, doctors should have the freedom to repackage and re-price their services. And payment should take into account the quality of the care that is delivered. Once physicians are liberated under Medicare, private insurers will follow.”

Ah, the catch here is that costs will rise. Then what? And by the way, moderate and liberal Democrats have been talking about improving “quality” at least since Bubba was in the WH.

• Don't cut Medicare. “The reform bills passed by the House and Senate cut Medicare by approximately $500 billion. This is wrong. There is no question that Medicare is on an unsustainable course; the government has promised far more than it can deliver. But this problem will not be solved by cutting Medicare in order to create new unfunded liabilities for young people.”

What conservatives (who in their heart of hearts never liked Medicare in the first place) do not mention is that the cuts to Medicare that congress has proposed are in reality cuts to Medicare Advantage programs, which pay doctors a hefty premium over plain vanilla Medicare. The Obama administration has tried to rein-in costs to pay for HC reform, for which conservatives should be applauding. And I’m sorry, if “unfunded liabilities for young people” mean that individuals—including children—currently without health insurance have some health security, well, just call me a bleeding heart.

• Protect early retirees. “More than 80% of the 78 million baby boomers will likely retire before they become eligible for Medicare. This is often the most difficult time for individuals and families to find affordable insurance. A viable bridge to Medicare can be built by allowing employers to obtain individually owned insurance for their retirees at group rates; allowing them to deposit some or all of the premium amount for post-retirement insurance into a retiree's Health Savings Account; and giving employers and younger employees the ability to save tax-free for post-retirement health.”

This seems like a good idea and one that could be discussed at the White House health care summit next week. But this type of plan must ensure that benefits are available to all employees, not just the better off ones.

• Inform consumers. “Patients need to have clear, reliable data about cost and quality before they make decisions about their care. But finding such information is virtually impossible…”

Fine enough. But doctors also need “clear, reliable data.” The Democrats’ plan includes money for comparative effectiveness studies to examine the effectiveness of some treatments. But conservatives have resisted funding these studies. You can’t have it both ways!

• Eliminate junk lawsuits. “Last year the president pledged to consider civil justice reform. We do not need to study or test medical malpractice any longer: The current system is broken…”

Tort reform is fine as long as individuals seriously wronged or injured can recover reasonable damages. The caps Republicans suggest are simply too low. And “loser pays laws” which Messrs. Gingrich and Goodman advocate would be devastatingly effective in closing off any suits to begin with.

• Make medical breakthroughs accessible to patients. Breakthrough drugs, innovative devices and new therapies to treat rare, complex diseases as well as chronic conditions should be sped to the market. We can do this by cutting red tape before and during review by the Food and Drug Administration and by deploying information technology to monitor the quality of drugs and devices once they reach the marketplace.

I am for faster access to new therapies (after all, pharma companies are my clients). But no one has an appetite for shortcutting the FDA’s safety and effectiveness review process (which some label “red tape.”). And if we are monitoring the quality of drugs and devices post-approval, aren’t we also interested in measuring their effectiveness relative to earlier products?

# # #

Checklist: Check.

I haven’t read Atul Gawande’s new book, “The Checklist Manifesto,” but I am anxious to do so—maybe as soon as I finish David Ploffle’s congratulatory “The Audacity to Win.” But I like the idea Dr. Gawande discusses, as reported on the PBS Newshour (http://www.pbs.org/newshour/bb/health/jan-june10/gawande_02-08.html) and elsewhere. His premise is that in a world of rising magnitudes of complexity, professionals should revert to the most basic of management tools, the simple checklist, to ensure success.

It’s a great example of how something oh so simple can have a major impact on events. An example: in Michigan every hospital adopted a “cleanliness checklist to help control infections. The result: a 2/3 reduction in hospital-acquired infections, the saving of 1,500 lives and a cost savings of more than $200 million.

(The late great television program “ER” incorporated checklists in the surgical settings in one of its final episodes.)

Now down the food chain to health care public relations. The importance of checklists struck me when I was reliving some old business plans account teams developed for p.r. clients. Many were awesome, but others were, well, less so. Two of sand traps public relations executives fall into are the allure of developing everything from scratch or piling one idea (good or bad) on top of another, as if a bigger pile of recommendations is necessarily a better pile.

The most successful teams and agencies may or may not have a new business or a new year planning processes—sometimes I think the “proprietary” processes are so much hooey. But what they will do is ensure that each issue the client faces is addressed and that each audience is accounted for. In order not to go crazy in the business development process, these winning teams will generally follow established checklists mandating when each task must be achieved and who is accountable for it. (I’ve created several such checklists. Let me know if you’d like to see them.)

Checklists: it’s such a simple concept it is amazing that it take a surgeon of Dr. Gawande’s stature to remind us of their importance.

Surgery-related dementia in elderly

Over chardonnay and port Sunday, two friends who are anesthesia experts told me of an interesting observation: Health care professionals are anecdotally reporting that there is a very high rate of dementia in elderly patients following surgery. We are already aware that open-heart surgery patients often have memory lapses and “chemo brain” is a known though not inevitable consequence of chemotherapy.

But this is a newly reported phenomenon and despite being whispered about in hospitals, there are no clinical trials to map out its legitimacy and severity. In fact, my friends say there’s little incentive to fund research in this area since the patients are typically very old and do not have long lives ahead of them.

But as our population becomes hoarier, post-surgery dementia, if confirmed, could become a roadblock to good quality of life in later years. Elderly individuals now are participating in activities undreamed of a generation or two ago. Long distance running, working, gee, even dating, are activities not uncommon even among people in their 80’s. Will they be as eager to go under the knife if they believe that medical procedures designed to help them may in fact hobble their ability to reason, socialize and live independently?

As health care communicators, how will we allay their fears and help them weigh the risks of surgery with possible consequences?