Question of the day- Mayo Clinic and marketing

Mayo Clinic has no marketing budget, only PR.

They have never done a direct mail campaign, print or electronic media advertisements or any other traditional types of marketing.

Yet everyone knows who they are and what to expect in the way of customer service and quality.

So Quality + Reputation + PR = Success. So on a local level, why do hospitals spend endless dollars on misleading ads and claims when the answer to market success lies before their very feet?