Lisa Farren (Host): Hello everyone and welcome to Crushing Healthcare where we explore diverse perspectives regarding the state of healthcare today and gutsy visions for a more affordable, accessible, equitable, and sustainable healthcare model. So I'm excited for today's episode. We are inundated with ads each day from all angles.

I think everyone can speak to this directly, from TV, radio, billboards to social media feeds and anything and everything in between. Everything from prescription drug commercials instructing us to talk to your doctor about, to ads for at-home testing, wearable medical devices. They fill our screens, our social feeds.

The healthcare industry is big business and it has taken a consumer packaged goods approach to advertising, shifting us toward speaking directly to consumers. It's the consumerization of healthcare, if you will. The appeal is obvious. Patients are curious. Patients want more control over their health, and they're often drawn to solutions that promise empowerment, convenience, and even hope, of course.

But beneath all that allure lies a complex web of questions and risks. What happens when the demand for a medication, a test, or a device is created by advertising rather than guided by a trained medical professional? How do we balance access to information with the dangers of misinformation, overuse, or just unnecessary treatment?

 And who ultimately benefits when marketing replaces medical oversight; the patient or the manufacturer, the company promoting the device or the medication. So in this episode, we're going to explore all of these things, the rise of direct-to-patient marketing. And I'm going to preface it by saying, in some cases we may say direct-to-patient or direct-to-consumer.

In this case, the consumer equals the patient. We're going to look at everyone in that sort of respect, if you will. So we are going to explore all of that specifically around pharmaceutical ads, why and how this type of advertising emerged. Why it's growing, what makes it so pervasive and what are the real pitfalls that it presents for patients and the healthcare system as a whole.

 So, with that, let's get started. I'm going to introduce Dr. Jim Uberti. Welcome back. He's a recurring guest on Crushing Healthcare. We're really excited to have him. Dr. Uberti is the Medical Director at SoNE Health, where he works closely with providers to support them in maximizing performance improvement and clinical outcomes.

Dr. Uberti is a recognized leader and advocate for value-based care. His career as a primary care internist spans more than 30 years in the greater Waterbury, Connecticut market with experience practicing medicine as both a physician employed by a hospital system, as well as an independent physician and a partner in a primary care medical practice.

 And then today I'm going to be serving in a new role. I typically just facilitate the Crushing Healthcare podcast, but today I'm going to be wearing my marketing hat. I've been in the marketing field my entire career working in a variety of industries with a focus on both, business-to-consumer and business-to-business marketing and communications.

I am the Director of Marketing and Communications at SoNE Health. I've held the professional certified marketing PCM designation from the American Marketing Association since 2001. So good or bad, I can't turn off my marketing brain. More often than not I, hyper analyse ads and other marketing content, I can't help myself.

So I'm excited for today's discussion and to share my marketing perspective. All right, so after all that, Dr. Uberti, how did we get here? Marketing directly to patients is relatively new, particularly with prescription drugs. Historically, the pharmaceutical companies relied on sales reps visiting the physician offices to promote their drugs, but why this strategy shift?

James Uberti, MD, MPH: Well, good morning Lisa. I'm really happy to be here discussing this topic with you. It's been one that's I've noted and probably been troubled by for a long time. My wife would probably testify under oath that as I'm watching a sports event or news on television, my molars are grinding through the various drug ads that populate those broadcasts.

And so I'm really pleased this morning to be uh, having a discussion with an expert in marketing who can talk to me about some of the techniques that the drug companies are using in their advertising. But I first wanted to set the stage by describing how we got here, where did we get to a point where drug ads are so dominating the broadcasts that we watch, and other social media that we digest.

So back in the early 1900s, we had snake oil salesmen. There was all kinds of stuff being advertised at Carnivals and other places, making all kinds of claims, it was completely the Wild West. There was no regulations or anything like that. But then in the forties, fifties, and sixties; through a lot of research and development, very promising drugs began to come out, especially antibiotics for example, which really revolutionized care of infections. So in 1969, the FDA issued some final regulations for drug advertising. They're still roughly in place today. They stipulated that ads could not be false or misleading, that there needed to be a fair balance.

We'll use that term fair balance a lot in our discussion of information describing benefits of a drug and the risks of a drug. The ads were to include facts that were material to product's advertised uses, and they're also supposed to include a brief summary that mentions every risk described in the drug's labeling.

So with these regulations starting in the late sixties, pharma for the next, couple of decades really focused promotional efforts solely on physicians. However, they began to then heavily invest in influencing consumers. And the FDA more or less permitted this expansion. And this more or less also correlated with the patient's rights movement.

Remember we had more emphasis on informed consent, an informed consumer, if you will, patient decision making, et cetera. So in 1981, Merck pharmaceuticals produced the first print ad, and it was a good one. It was for the pneumonia vaccine Pneumovax, and it was published in Reader's Digest. But then in 1983, Boots Pharmaceuticals broadcast their first ad on television.

It was actually a branded form of ibuprofen, the FDA looked at this and quickly pulled it because they had concerns, legitimate about self-diagnosis. And so then from 83 to 85, the FDA requested a voluntary moratorium of all ads while it studied the issue. And so they then issued adjusted regulations that required advertisers to include a detailed summary of the risks of a drug and how to obtain that information.

This was viewed as onerous by pharma companies in limited ads. Then in 1997, the FDA further eased regulations. It allowed for quote major risk unquote summaries instead of the full quote, brief summary, unquote, in print and broadcast ads. So this change was seen as a major factor in the boom of DTCA that followed, and DTCA direct-to-consumer-advertising.

 And so in 2004, the FDA eliminated the need to reprint complete prescribing information in print ads, replacing it with a simplified brief summary. At that point, spending on DTCA really took off. It hit 5 billion in 2006, most of it on TV commercials. So at the present time, this basic framework from the late 1980s remains in place.

But the US remains one of only two countries in the world, New Zealand being the other that even allows direct-to-consumer advertising for prescription drugs. So I just want to, before we go into our discussion, I also want to just talk about the different types of direct-to-consumer-advertising, which is basically an effort by pharmaceutical companies to promote their products directly to patients. The first is a help seeking ad. This is only information about a medical condition. It encourages the patient to contact their physician, but it does not mention a product. A second is a reminder ad. It includes the product's name and may provide information about the product's strength, dosage, and price, but it does not mention any indication or make any claims. For these first two types, there's no fair and balance requirement. There's no required brief summary or major statement regarding the risks of the drug. The third is the one we see all the time now. It's the most common, it's the product claim ad. It mentions the product and its indications.

And it includes its efficiency, its efficacy rather, or safety claims. This is where fair and balance regulations apply. The risks are required to be included in a brief summary. If it's a broadcast ad, the risks must be included in a major statement, but with adequate provision for access to a brief summary.

And that's usually what was in the past an 800 number and now is typically a website. So the FDA regulated ads are required to be truthful and present a fair and balance of the drug's risk and benefits. But does this happen, Lisa?

Host: Well, that was a really good summary. I'm going to start by that. And I did not realize that it was just us here in the US and New Zealand. So that's a little disturbing actually. So, as I said before, I, from the marketing perspective, I can sort of understand why this has developed over time.

Healthcare is, it's a service or in some cases a product, in the case of pharmaceuticals and like everything else, there's the consumerization of selling and manufacturing, selling, bringing goods to market. So I can see why the progression happened. And you know, there are definitely, I think I could see some positive and negatives, which I think we'll talk about in a bit.

But, it's interesting because there's just so much to it. And I do in some ways when I think of marketing, thinking that knowledge is power. So I think it could be good to educate consumers, but at the same time, there's, there's just so much to this. Again, knowledge is power.

Knowledgeable consumers, maybe they shop around, which then creates a fruitful atmosphere for marketplace competition. Competition, is a driver for innovation, but yeah, there's a lot to it. And the ads can be, I don't want to say misleading, but there's definitely some different strategies used in these ads when looking at them through the marketing lens to get people to do what it is they want them to do, which essentially is talk to the doctor, talk to their healthcare provider about a particular drug.

 So they use emotional strategies and in some cases, it could be fear, like, you are not going to get better unless you pick this particular drug. Persuasion, empowerment, that's a big one. The sense that I can do this myself, I can do the research. I can go to my doctor and say this is what I want.

 There's definitely drawbacks to that and I know you can speak to that, but that's a big one. And of course, convenience. Sometimes distrust I've seen in the ads, and that's the idea that, this one I don't particularly like, but I get the sense that they're sending a subliminal message that somehow their healthcare provider is holding something back.

Like there's something that just, they're not giving them all the information. And so the pharmaceutical companies are saying this drug is the one you need to ask for. And of course, peace of mind. But there's a lot of non-specific approaches. They often are very nondescript. Are you feeling tired?

Lack of interest in everyday activities, then maybe you need to ask your doctor about this. So generalizing symptoms, amplifying symptoms like, oh, you're feeling tired. Well, that's a really bad sign. You need this drug. We also have seen most recently, at least I've started to notice them more often, is celebrity testimonials for drugs. And it's funny because I can see that for sneakers if you will, but selling drugs, oh, this musical artist or this actor uses this drug, so, gosh, it's gotta be good because they have unlimited funds.

They have access to all the options to treat whatever it is. And if they're choosing this one, then I need to choose this one too. There's also in the ads, which, I find comical and you mentioned that your wife could attest to it. My husband could at attest to this is anytime I see the ads, I just burst out laughing. We spend so much time picking apart the ads. There's all these sort of distraction tactics in the ads with visuals and music. And honestly, are this many people in the world dancing in their kitchen or dancing in the street for that matter? I feel like everyone's dancing no matter what they're doing because they're on this particular drug and they're just feeling so great.

Or the visual imagery takes front seat to the voiceover or if they have disclaimers and small print I feel like it's all to distract you. And it's this idea that we're visual people, we tend to be much more visual. And so we see that and our brain says, wow, look at that.

We tune out and we put to the backseat, if you will, what's being said. And instead it's like, look at this. If I take this, I am going to be able to like I said, dance in the street, or I am going to have so much fun fishing with my grandson. There's just so many things and I find that really funny.

I also find the jingles and the songs just absolutely comical. That's a big one. And that is what's called earworm. If you've ever had like a song stuck in your head and you can't get it out, that's what they're trying to do with the jingles. Is they're trying to get earworms so that even when like you're not paying attention to the ad, two days later, it's in your head and you can't get it out. So they're hijacking your brain to some degree, if you will.

James Uberti, MD, MPH: So a couple of comments. First of all, regarding the jingles. The one that comes to mind pretty quickly is Ozempic and they use that song by Pilot, a terrible song from the seventies with that oh, oh Ozempic thing. It, it's brutal. It's brutal. Listen to, you also mentioned celebrities.

Yeah. Lady Gaga is advertising Nurtec. Cyndi Lauper does a, psoriatic drug but the poster child for using a, well, I'll say it's a celebrity, but it was a politician. It was Bob Dole doing Viagra commercials. Here was a very serious, longstanding statesman, US Senator, Presidential candidate doing a erectile dysfunction drug.

And that got a lot of attention, a lot of attention. And that was probably the start of using high profile individuals for advertising. What you said at the beginning though, there's positives and negatives, and certainly the positives is in regard to patient empowerment, right?

An informed patient, consumers get information and they're empowered to seek and obtain more information, take more active role in their own healthcare. One could argue that it improves compliance because consumers are encouraged to follow the prescribed treatment, and there's some disease awareness also and of a condition that otherwise might be overlooked.

I think the best examples may be a shingles vaccine, which is quite effective. It's been very good. Minimal side effects and shingles is a pretty nasty illness when it's contracted. So in that way it's good. But you also mentioned Lisa nonspecific symptoms. There's lots of that. The biggest hypochondriacs are students in medical school.

I was one of them at one time, way back when, we read about all these horrible diseases, a lot of them nonspecific symptoms, which we all think we have at some point during the course. And so there, there can be misleading information. It's often biased. It often highlights benefits more effectively than the risks.

There's maybe inappropriate prescribing to patients that have requested a specific drug, so it might be in an unnecessary treatment. There's certainly economic burden, which we can, you know, perhaps discuss a little later on as the impact on the health system and certainly can undermine a physician-patient relationship.

Doctor, why didn't you tell me that I had this disease that I think I have? Or why didn't you consider this when you were treating me with this other drug? Why didn't you consider this drug I just saw on television the other day? So it can undermine the physician decision making.

And therefore the trust that is the essence of the doctor-patient relationship because patients now may challenge their doctor's recommendations. And also I'll even add, there's a potential for polypharmacy, which is always a concern and the enhancement of drug interactions, which causes a lot of iatrogenic or unintended illness and complications.

So I look at this as direct-to-consumer-advertising as a scale, with balance of positives and negatives. But I do think that we've shifted more toward the negative side in recent years.

Host: Particularly as it's just become more pervasive and the ads are getting, I think from the marketing perspective, again, I think they're getting more and more complex. They're using more of these sort of strategies that I mentioned that just when you're watching television or reading an ad, you're not thinking that you're being persuaded.

But there really is some, a lot of tactics and that whole also just, I know with social media, the whole FOMO, fear of missing out on so many things. I feel like that's really injected itself into these ads as well. Like, somehow you're going to miss out on life, a quality of life, living a longer life, better life if you don't take this particular drug.

James Uberti, MD, MPH: Sure and to your point, all those people in those ads look very happy. They're just enjoying life to the fullest. They look young and healthy and vibrant and even heavyset people dancing on Jardiance commercials and everybody's just enjoying life to the max. And you're correct. That's a strong driver these days.

 I did want to ask you about the modalities because TV advertisement is what we see the most. But it actually ticked down a little bit. If you look at the data from 2020-2025 TV ads ticked down in 24 a little bit, digital has really increased with online. And, a lot of the pharma ads now are the third biggest category for not just linear tv, but also streaming.

Now radio and print have just practically disappeared. So what do you think of the modalities that are being utilized?

Host: So digital does make sense. Our world is digital and becoming increasingly so with each day. And with the use of certain algorithms on social media, once you know you're on some website and you click on something, it's going to track that and it's going to know. And so somehow it figures out, oh this person may have eczema, so I'm going to serve up, this ad. It is very pervasive. From the perspective of the marketing budget, if you will, the cost per impression on digital tends to be less. So I think that's also another reason. And yes, we tend to be just digital consumers at this point.

That's how we digest our information. Although I can say I do still see these types of ads in print, particularly magazines. And sometimes they do like two page spreads, which you know, is not cheap. But it's interesting because the marketing, the advertising, different channels, the pendulum swings as time goes on.

And we really moved away from print for quite a long time. But print is having sort of a resurgence to some degree. And I'm seeing it go up. So I'm not surprised that there is more print and TV, whether it's network television, or streaming. Again, it's digital. It's so easy to do that. And a lot of times with streaming ads on television, they also can target you. So I think that makes sense because it's easier to target who potentially they're reaching based on what they're selling and what they're trying to cure or treat.

But there's a lot of different methods and honestly, I think it's going to continue to expand. I think they're going to find new ways to seep into our lives and into our minds. Not just the channels, but the tactics that they're going to use in the ads. I've noticed that consumers over time, they do get a little savvy.

And so when I had this conversation similarly with a friend who is not in marketing, she was like, oh yeah, I've noticed this and I've noticed this. Like, oh, well that's interesting that I look at it through the marketing lens. So I tend to see it right away. But I think people are becoming more aware.

So just like if anything, it's going to morph and they're going to continue to try and get into our brains and sell their products. In this case, pharmaceuticals.

James Uberti, MD, MPH: No matter what the modality being used, clearly as a professional, I've noticed that they've increasingly bypassed marketing directly to professionals, and now they're directly addressing patients in the public. However, there's a method behind that madness, if you will, in that among the top selling drugs, the lowest level of added benefit, those drugs with the lowest level of added benefit had the most advertising that went direct to patients rather than doctors. So you're taking drugs that are less efficacious. Professionals may understand that, not be so willing to prescribe them and say, well, you know what, we're going to go directly to your patient and make them demand it from you.

And they do make drugs seem like, as you said, these must have treatments. And they do this while minimizing what is lackluster or really less than impressive efficacy and a fair amount of risk.

Host: I'm curious, as a doctor, have you seen that firsthand? Patient coming to you and asking or even demanding a particular drug because they saw the ad and sort of have to be put in this position to really educate them and talk them down from the marketing ledge, if you will?

They've been sold on something even though they don't know if they need it or not.

James Uberti, MD, MPH: Yeah, that's a great point. There's always this balance between wanting the patient to make the most informed decision possible. I always took the position that the more information my patients had, the better, the more questions they asked, the better. And they certainly have a right to information about their treatment options.

And, whatever decisions they make, as far as taking a medication or purchasing a medication, whatever the case may be. But you have to balance that with the appropriateness of a patient making a self-diagnosis based on a television ad or even the ethics of an industry now that promotes these potentially dangerous drugs.

They're not without significant side effects at times. And and the pharma companies sort of hide behind the language of individual rights, right. To support what are otherwise commercial activities. So if the relationship with a patient is good, they're not going to make demands.

They're not going to demand it, but they will ask you about it. And yes, it does take time to kind of walk them through and say, no I prescribed this medication because of this, and this. I would not recommend that drug, which you just saw advertised at the during the Super Bowl because of this, and this.

 And so yeah, it is time consuming. And again, sometimes you get that skeptical look on a patient's face, like, you've withheld this from me, you know, that kind of thing. So there's almost a cynicism in those ads. Like, your doctor, whether it be a PCP or specialist, was not savvy enough or smart enough to recognize this disease that you may have or isn't aware of this particular drug, which you need to ask him or her about because they weren't aware. So it really, I think in that way can undermine a physician-patient relationship.

Host: I really enjoy this topic. Because of course it's marketing, so this really goes beyond pharmaceuticals. There are many other things that are being marketed to patients. So maybe we can pick this conversation up another time, Dr. Uberti, and dive into some of those as well and expand. What do you think?

James Uberti, MD, MPH: I would love to, a lot more to talk about about this topic. Be happy to.

Host: Awesome. Alright, great. Well, I really appreciate you taking the time to chat with us today. Remember, we all have a role to play in transforming healthcare, so join us in Crushing Healthcare.