When I began my career in healthcare marketing in the mid 1970s, I thought I was making a significant positive difference to the inaccurately labeled “health care system”. Back then, essentially nobody did, wrote, or even said much about things like patient satisfaction, patient-centered care, etc. nor spent anything remotely resembling the kind of current marketing budgets. In essence, there were no marketing budgets, no marketers, and no marketing in healthcare at all.

I was lucky enough to get in on the early wave of its development and implementation, with two books and a host of articles, as well as some delightful consulting engagement. With nobody else marketing, it was a simple matter to achieve dramatic improvements in market share, revenue, and profits for my clients, simply by doing pretty basic marketing stuff, like devising more convenient and satisfying patients experiences, and doing the same for physicians where referrals were needed.

To describe the prevailing situation back then would make it sound like the Dark Ages, compared to the emphasis on patient and physician experience management, direct-to-consumer (DTC) advertising, the thousands of people now engaged in marketing efforts, and the awareness among executives of the necessity for significant spending thereon. We have come a long way, though I confess, not necessarily in the direction I had anticipated back then.

My original aim was to combine doing a better job of identifying and meeting patients’ and physicians’ needs, wants, and expectations as a way to achieve a truly WIN/WIN result for the healthcare organizations who did so earliest and best. My first consulting engagement in 1974 or thereabouts turned around a failing hospital-sponsored primary care center into what became a highly successful “chain” of such centers and a major boost to the fortunes of the hospital involved. But this was due to making the product, place and price elements of what the clinics offered dramatically better and more attractive/satisfying for patients, not through expensive advertising, which did not even exist at that time.

Since then, marketing has taken off dramatically in health care, and hardly any provider can afford to ignore it. I made an excellent living at it, and have been able to retire in comfort to a life of “freelance scholarship”, with a lot of research and writing, and frequent enough consulting engagements to keep up with its present developments. But it is clear that marketing in health care has had a lot of unfortunate effects that I never considered or anticipated, and we are all suffering from them.

As is pointed out concisely and persuasively in another blog, ”Health Status Is Not the Only Predictor of Medical Costs”. I recall reading about this back in graduate school before the marketing idea emerged, thinking it was an interesting factoid, but not really connecting it to an opportunity that marketing can address. But it is clear that the natural drive for healthcare providers, drug manufacturers, and other purveyors to succeed, has led them to exploit this potential, and not entirely to the benefit of patients.

The blog reminds us that only about 20% of healthcare use is explained solely by health status, though the correlation between status and use is strong, particularly at extreme levels of good or bad health. But people with similar levels of health/illness overall do not use the same levels of care. Their use, the other 80% at least, is more reflective of individual attitudes and preferences, insurance coverage, provider (“supply-based) effects, and economic incentives that apply to remaining at work vs. taking time off. [W. Lynch & H. Gardner “If We Only Consider One Possible Cause, We Will Be Left with Only One Type of Solution” Health as Human Capital, Mar 2, 2008]

Numerous studies have shown that economic incentives and geographic variations in the supply and care philosophy of physicians have yielded enormous variations in how a given patient with a given condition will be treated. Such variations come with very little evidence that more treatment is better, and a lot of evidence that over-treatment makes the patient worse, to say nothing of the added costs that all of us end up bearing, one way or another. And marketing clearly has a lot to do with promoting over-treatment.

It is easy to put a lot of blame on pharmaceutical advertising, which has promoted widespread perceptions in new “diseases” such as “restless leg syndrome” as well as new ways of dealing with old problems, such as “erectile dysfunction”. When I began my career, the only intent in marketing was to win more patients to the providers I worked with, not to drive up demand as a whole.

But to a great extent, it is impossible to separate the two. If healthcare becomes more attractive and satisfying for patients and physicians, it is bound to be used more. And all providers can benefit when a “rising tide” of increased demand “raises all boats” among providers of care. After many years of promoting the ER as a source of convenient care, with guarantees that patients will be seen within 30 minutes, for example, we now have a serious problem of overuse of ERs.

There is a “marketing” solution to this problem, of course, and many hospitals as well as the natural workings of the market have resulted in some significant “solutions”. Hospitals, themselves, along with insurers and employers, have “de-marketed” ER use with information campaigns, (“de-advertising?”), and the creation or support of alternatives, such as “fast-track” options to ERs on hospital campuses, “retail clinics”, and “urgent care centers”, though these often have trouble competing with the overwhelming market advantage that ERs have for patients of not being able to turn away non-paying patients.

The authors of the blog piece noted that they had used regression analysis to “predict” or account for medical costs in a large population, based on age, gender and general health ratings of its members. This combination of demographic and health factors achieved an R2 predictive success of only 11%, meaning that 89% of variations in use were due to other factors. It also predicted the differences in medical costs for employers with two different sets of incentive dynamics, but similar populations and illness. The expected costs of one, based on high-deductible health insurance and a consumer-directed health account, a culture of communicating the costs to employees of their employee benefits, and shared responsibility for time away from work, were over $2000 less per employee per year than costs for the other.

Perhaps more important, even when the second firm has a more educated workforce and more wellness programs, the differences in costs persist, because of the strong impact of the economic incentives on employees’ behaviors. While wellness programs and other efforts to improve employee health have been shown to save significantly through improved productivity and performance, apparently economic incentives can counter or at least reduce their effects.

To the extent that marketing promotes positive attitudes toward health care use over self-management of health and prudent management of one’s healthcare use, along with making one provider more preferred than another, it is part of the problem. But it is likely that altering economic incentives, along with the effective marketing of health and good self-health-management, will be necessary to “solve” the health care cost crisis. Efforts to make health insurance coverage universally available will not solve, but exacerbate this crisis, unless they are accompanied by ways to “de-market” unnecessary and avoidable health care use and expense.