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Friday, June 15, 2007

Oncologists accused of giving chemo.for profit not patient benefit

I do not want to believe that oncologists would give chemotherapy(CMT) to patients who they do not believe would likely benefit simply because they can make a profit on their mark-up on the drugs they administer. I have always had nothing but admiration for oncologists who day by day deal with seriously ill and dying patients and manage to be current and proficient in the variety of cancers they treat and the multiplicity of drug regimens and toxicities and complications.

The ones I have practiced with deserve to be called physicians with all the positive connotations that term can garner.

A recent article in the NYT paints a different picture of some oncologists. Here is some background.For a number of years CMT has been given in oncologists offices. The CMS and third party payers fees exceeded the costs to the docs so there is a make up profit involved. Recently, changes in CMS rules have cut the margin .

The gist of the NYT article is that oncologists are making up for the shortfall with an increase in volume of patients treated with CMT implying that some patients are being given CMT inappropriately.

NYT quotes Dr. Richard Deyo ,a professor at the University of Washington,describing him as a"expert in health care spending" as saying:

There's pretty good evidence at this point that there are plenty of patients for whom there's little hope,who are terminally ill,whom chemotherapy is not going to help, who get chemotherapy

That comment, like most of the NYT article, is heavy on accusations and generalizations and light on supporting data and facts. Dr. Deyo may have analyzed numerous cases and determined that in many instances the CMT was inappropriate but if so I would like to see that analysis. What is the nature of the evidence for his statement? I would be very surprised if Deyo's comments are based on patient level data in which cases are analysed by physicians expert in CMT and wherein inappropriate treatment was found in "plenty of patients". I would not be surprised if that type thing has happened in some cases but I doubt that level of data is what Deyo's statements is based on. Broad brush, coarse grain data is the more likely currency for the type outcomes research that Deyo has been known for (and has gained a well deserved reputation for his work in low back pain treatment outcomes). He may have well done some outcomes research in the CMT area and his comments may have based on that but if there is such data he should have made that fact known to the NYT reporter so the article would appear less like a typical drive-by-media encounter. If he does not have that data, then he may have done disservice to the thousands of patients now receiving CMT who may now wonder if it is avarice and not likelihood of benefit that formed the basis of the decision to treat them.


Anonymous said...

I work in the Oncology field and can attest to seeing first hand how the doctors will prescribe for profit. Look no further than the current Arenesp debacle, and how doctors used EPO's as a main revenue generator. It is no secret in the sales community that ever since reimbursement changed, Oncologist have become business men.

Greg Pawelski said...

The shift, more than 20 years ago, from the institution-based, inpatient setting to community-based, ambulatory sites for treating the majority of the nation's cancer patients has prompted in large part additional costs to the government and Medicare beneficiaries. The Chemotherapy Concession gave oncologists the financial incentive to select certain forms of chemotherapy over others because they receive higher reimbursement.

This was first brought to attention at a Medicare Advisory Panel meeting in 1999 in Baltimore. There was a gastroenterologist in attendance who complained that Medicare had cut his reimbursement for colonoscopies from $400 to $108 and how all the doctors in his large, multi-specialty internal medicine group were hurting, save for two medical oncologists, whom he said were making a killing running their in-office retail pharmacies.

Typically, doctors give patients prescriptions for drugs that are then filled at pharmacies. But medical oncologists bought chemotherapy drugs themselves, often at prices discounted by drug manufacturers trying to sell more of their products and then administered them intravenously to patients in their offices.

Not only do the medical oncologists have complete logistical, administrative, marketing and financial control of the process, they also control the knowledge of the process. The result is that the medical oncologist selects the product, selects the vendor, decides the markup, conceals details of the transaction to the degree they wish, and delivers the product on their own terms including time, place and modality.

A joint Michigan/Harvard study authored by Drs. Joseph Newhouse and Craig C. Earle, entitled, "Does reimbursement influence chemotherapy treatment for cancer patients," confirmed that before the new Medicare reform, medical oncologists chose cancer chemotherapy based on how much money the chemotherapy earned the medical oncologist. A survey by Dr. Neil Love, "Patterns of Care," showed results that the Medicare reforms still were not working. It was still an impossible conflict of interest.

A patient wants a physician's decision to be based on experience, clinical information, new basic science insights and the like, not on how much money the doctor gets to keep. A patient should know if there are any financial incentives at work in determining what cancer drugs are being prescribed.

It's not that all medical oncologists are bad people. It's just that the system is rotten and still an impossible conflict of interest. Some oncologists prescribe chemotherapy drugs with equal efficacies and toxicities. I would imagine that some are influenced by the whole state of affairs, possibly without even entirely admitting it. There are so many ways for humans to rationalize their behavior.

There is some innate goodness of people who go into oncology. At the time when most oncologists practicing today made the decision to become oncologists, there was no Chemotherapy Concession. Most of them probably had a personal life experience which created the calling to do battle against the great crab. At the time when people make their most important decisions in life, they are in the most idealitstic period of their lives.

The government wasn't reducing payment for cancer care under the new Medicare bill. They were simply reducing overpayment for chemotherapy drugs, and paying cancer specialists the same as other physicians. The government can't afford to overpay for drugs, in an era where all these new drugs are being introduced, which are fantastically expensive.

Although the new Medicare bill tried to curtail the Chemotherapy Concession, private insurers still go along with it. What needs to be done is to remove the profit incentive from the choice of drug treatments. Medical oncologists should be taken out of the retail pharmacy business and let them be doctors again.

james gaulte said...

I said that I "did not want to believe" that oncologists were so driven by profit as to let their treatment decisions be determined or at least strongly influenced by profit.The above letter and other comments I have come across in other blogs unfortunaely makes me accept the idea that that practice has occured more times than "I wont to believe" Say it isn't so , Joe.

Anonymous said...

James, I actually felt the same, I didn't want to believe that finances influenced oncologists but I have to say different now since I'm a board certified hospice and palliative medicine physician and work closely with oncologists. There are other reasons why (I believe) and I have posted them on my blog. I have two entries you may find intersting, one is entitled "Letting the Doctor Off the Hook" and "Why Don't They Stop Chemo." I to have seen too many dying patients strapped to hanging bags of chemo. Maybe it's the population I'm exposed to and I don't see the other thousands benefiting from chemo. Anyway, thanks for the blog entry and good posts.

Anonymous said...

AS a AOCNP, currently not working in oncology, I know without a doubt that oncologist give chemo and EPOs or anything else they can inject for profit. I left my last job because I couldn't sleep at night. The doctor should be in jail. As a drug rep told me off the record 70% of oncologist will choose the drug with a higher profit margin, when other less expensive drugs would do just as well.