gpawelski Posted March 10, 2006 Share Posted March 10, 2006 Reimbursements Sway Oncologists' Drug Choices The shift, almost 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 Drug Concession gave oncologists the financial incentive to select certain forms of chemotherapy over others because they receive higher reimbursement. 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 administer them intravenously to patients in their offices. Not only does the oncologist have complete logistical, administrative, marketing and financial control of the process, they also control the "knowledge" of the process. The result is that the 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. There was a joint Michigan/Harvard study authored by Drs. Joseph Newhouse and Craig C. Earle, entitled "Does reimbursement influence chemotherapy treatment for cancer patients?" It confirmed that medical oncologists choosed cancer chemotherapy based on how much money the chemotherapy earns the medical oncologist. The authors documented a clear association between reimbursement to oncologists for the chemotherapy and the regimens which oncologists select for their cancer patients. In other words, oncologists tended to base their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist. The study adds to the 'smoking gun' survey by Dr. Neil Love, entitled "Patterns of Care." One of the results of this survey shows that for first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists (who do not derive personal profit from infusion chemotherapy) prescribed an oral dose drug (capecitabine), while only 13% prescribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel. In contrast, among the community-based oncologists (who do derive personal profit from infusion chemotherapy), only 18% prescribed the oral dose drug (capecitabine), while 75% prescribed infusion drugs, and 29% prescribed the expensive, highly remunerative drug docetaxel. While the Michigan/Harvard study showed results before the new Medicare reform, the Patterns of Care study showed results that the Medicare reforms are still not working. It is still an impossible conflict of interest. And the existence of this profit motive in drug selection has been one of the major factors working against the individualization of cancer chemotherapy based on testing the cancer biology. Two scientific studies giving us a dose of reality that once a decision to give chemotherapy is taken, oncologists receiving more-generous Medicare reimbursements used more-costly treatment regimens. Source: Online Journal of Health Ethics, Vol 1, No 1 (2006) http://ethicsjournal.umc.edu/ojs2/index ... le/view/50 Quote Link to comment Share on other sites More sharing options...
karen335 Posted March 10, 2006 Share Posted March 10, 2006 Thanks Greg, How true. It all boils down to the bottom line.. Karen Quote Link to comment Share on other sites More sharing options...
dadstimeon Posted March 10, 2006 Share Posted March 10, 2006 Very Interesting--Just my two cents worth. Don't believe that is the case with my oncologists and the final decision is mine regardless. I know she has my best interest in helping me and nothing to do with money or politics. Quote Link to comment Share on other sites More sharing options...
gpawelski Posted March 10, 2006 Author Share Posted March 10, 2006 It's not that all oncologists are bad people. It's just that it is an impossible conflict of interest (i.e. it's the SYSTEM which is rotten). 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. The solution is not to put the doctors in jail, it's to change the system. Take physicians out of the retail pharmacy business and force them to be doctors again! Quote Link to comment Share on other sites More sharing options...
dadstimeon Posted March 10, 2006 Share Posted March 10, 2006 Everybody has complains about the system, me too--Don't know what the answer is but until something changes this is what we have. Changes are needed for sure your right, would be nice to see that, so every body gets a fair shake. Still very interesting, keep up the great flow of information you always provide. Quote Link to comment Share on other sites More sharing options...
gpawelski Posted March 12, 2006 Author Share Posted March 12, 2006 On a personal note, I didn't need two scientific "evidence-based" studies to tell me that my wife's oncologists at our so-called regional cancer center, had the incentive to prescribe a $15,000 Taxol/Carboplatin combination to a patient who is platinum-resistant, instead of a $1,500 alkylating agent regimen. It is commonplace (after six months) to give the same treatment to a recurrence as was given for the original tumor. But coming across these two studies, and the Dr. Katharina Pachmann study about Taxol's release of circulating tumor cells (a.k.a. brain mets) does answer most of the underlying questions I've had over these last few years (and the hundreds of emails). Quote Link to comment Share on other sites More sharing options...
cindi o'h Posted March 12, 2006 Share Posted March 12, 2006 gdpawel.. this is the first I hear about Dr. Katharina Pachmann's study on taxol and tumor cells/ brain mets. Where to get a synopsis? Thanks. Cindi o'h Quote Link to comment Share on other sites More sharing options...
gpawelski Posted March 12, 2006 Author Share Posted March 12, 2006 An article in the May 2005 issue of Oncology News International (Vol. 14, No.5) reported the Dr. Katharina Pachmann study. It said that ironically, paclitaxel produces the greatest degree of tumor shrinkage (a clinical response) but also the greatest release of circulating tumor cells. Circulating tumor cells (CTCs) are cancer cells that have detached from solid tumors and entered the blood stream. This can begin the process of metastasis, the most life-threatening aspect of cancer. To metastasize, or spread cancer to other sites in the body, CTCs travel through the blood and can take root in another tissue or organ. Dr. Pachmann said that this observation corresponds with results found in patients that tumor response does not mean increased survival. The study has shown that in three different paclitaxel (taxol) containing regimens, as the tumor collapses (a clinical response, not cure), it produces the greatest release of circulating tumor cells. The study has not looked at any other combination regimens. Using a technique (CellSearch) that quantifies circulating tumor cells, investigators have shown that chemotherapy with paclitaxel (taxol) causes a massive release of cells into the circulation, while at the same time reducing the size of the tumor. The finding could help explain the fact that complete pathologic responses do not correlate well with improvements in survival. (Oncol News Int'l, Vol 14, #5, May '05) And a chemo-induced gene mutation can happen when the original chemo received does not work. The cancer comes back. When it does this, the cancer comes back more aggressively. The mutagenic effects (changes in form) of chemotherapy on a genetically-unstable tumor, drives the tumor into a state of more aggressive behavior. You might kill off a whole lot of cancer, only to cause a mutation in the remaining cancer, such that the remaining cancer behaves in a more aggressive fashion. Like when chemotherapy on an ER+ cancer brings about a remission, but in the process also causes any remaining cancer to become ER-. Quote Link to comment Share on other sites More sharing options...
Linda661 Posted March 12, 2006 Share Posted March 12, 2006 gdpawel: I am brand new to looking into this section of the bboard, and I think I need to quit hyperventilating about what I just read in this thread....this is scary stuff to a newbie caregiver. My mom is on taxol/carbo.....does this mean she probably will end up with mets due to treatment????? Gosh -- when should I insist on new scans for that (which the doctors probably won't order of their own accord). Knowing I will probably find ALOT of useful links and info. along the way with this group, I am gonna ask this now anyway: Is there a selection of material you (or anyone following this) would recommend to help inform a caregiver in this regard? We have the expense issue going here as well, but I am most interested in what therapies actually seem to work best that might minimize the release of free-floating cancer cells (if there is such a thing). Sort of like "the top 10" list of things I/we should be on top off in the treatment venue with our doctors from what current and credible research shows? This is probably a tall order, but I'll try it anyway! Would even be OK to start a new topic on it -- seems like with so many newcomers lately, alot of us would be interested in how to get up to speed "quickly." Linda Quote Link to comment Share on other sites More sharing options...
karen335 Posted March 12, 2006 Share Posted March 12, 2006 Linda, I had Taxol/Carbo chemo. Last treatment was 10/2003. It is an individual situation. I have had brain met 2times now and surgery to remove Solitary brain met 2 yrs ago and recently(3 weeks ago) to remove brain met and necrosis from Stereotactic Radiation treatment after 1st surgery. I am doing great. It depends on an individuals health (other medical factors too, diabetes, BP, etc..) Just ask for scans every 3 months (CT's MRI's, bone scan and a PET every 6 months and don't take no for an answer) You are a good advocate for your mom and a nurse. You know the questions to ask. Also read alot. Pick and choose words in your mom's medical reports, then look them up on the Net. That is what I do and I have learned so much and also from others too, like gd. We are all here to try and keep each other informed and aware... Don't be afraid of the known. Knowledge is power. Sending you and mom prayers. Hugs, Karen Quote Link to comment Share on other sites More sharing options...
gpawelski Posted March 13, 2006 Author Share Posted March 13, 2006 Linda Think of it as cautionary information. Cancer is a "cronic" disease (much like diabetes). One has to be vigilant about it. As Karen suggests about CT's, MRI's, Bone Scan's and Pet's, you need to try to be one step (or steps) ahead of it. Although my wife's medical records had the word "cure" in them (why, it's beyond me) from the results of her first cancer in 1972, it's not. A recurrence came twenty-four years later. At least she got twenty-four years because of good cancer medicine. However, as referenced by the two scientific studies above, times have changed. Obviously, a patient wants a physician's decision to be based on experience, clinical information, new basic science insights, etc., not on how much money the doctor gets to keep. If you are a patient, you should know if there are any financial incentives at work in determining what cancer drugs you are being prescribed. Ask your oncologist: Why are you prescribing these drugs? What is their published efficacy and toxicity in other patients with the same cancer? Do you have any research or financial interests in prescribing these drugs? Are these drugs a profit center for you in respect to reimbursement? A trusting partnership between doctor and patient that facilitates informed consent is the goal for many proactive patients. Such a partnership, however, may require an understanding of all the factors that lead to a treatment recommendation. In light of the precious little in the way of guidance from clinical trials with respect to best empiric therapy (where the only thing that has been proven to correlate with treatment decisions is reimbursement to the prescribing oncologist), and the importance of basing cancer treatment at least in part on patient preferences, it is entirely reasonable to support judicious application of laboratory tests which have been well characterized with respect to test accuracy. The results of the Pachmann study are coming out slowly and quietly (now that Taxol is off-patent) and indicate that Taxol-containing regimens didn't prolong survival over other more conventional and less expensive cytotoxic drugs. It may indeed give clinical response (tumor shrinkage), sometimes impressively, however, these are mostly short-lived and relapses after a response to taxanes are often dramatic. There is another study about the subject by Dr. Christos Kosmas (American Journal Clinical Oncology 2002;63:6-15). There are many cancer drug regimens, all of which have approximately the same probability of working. The tumors of different patients have different responses to chemotherapy. Tumors grow and spread in different ways and their response to treatment depends on these unique characteristics. The amount of chemotherapy that each patient can tolerate varies considerably from patient to patient. The system is overloaded with drugs and under loaded with wisdom and expertise for using them. It requires individualized treatment based on testing the individual properties of each patient's cancer. Also, as Karen says, knowledge is power. With it, you know how to challenge your doctors if you don't think things are right/questionable. Quote Link to comment Share on other sites More sharing options...
Linda661 Posted March 13, 2006 Share Posted March 13, 2006 First, thanks karen and gdpawel for your responses -- I am not a nurse, by the way, just one scared adult kid that is the only family support my mom has (mom was nurse-trained years ago): Ok, I am sure this is probably way off base and is buried in a bboard area that is probably not the best for this sort of thing, but I DON'T KNOW THE QUESTIONS TO ASK, I DON'T KNOW HOW TO BE VIGILANT YET WITH THIS DISEASE AND I AM SCARED...and, unfortunately, I can't spend alot of time in hit-and-miss reading/researching/computer search engine time with the mess I still have to deal with from my dad's recent passing and just trying to run things around here and hold "status quo" until some major family life changes can be made...I try to be one step ahead, but I don't know how to do that either with lung cancer....every time I challenge the doctors, they just seem to step in my face and ignore me; the only couple of productive questions I did ask that amounted to anything came from this group so far. At least from what I gather so far, all courses of treatment carry their risks/rewards and are highly individual -- "just hang in there" is the wisdom I get from this and pursue, pursue, pursue how to change course, depending on mom's response course. How do you even know when not to "jump the gun" on day-to-day changes? Honestly, I swear I could be paranoid with that sort of thing right now.......mom is now 3 days into a "bad zone" with chills/hot flashes, fever (just below where you are supposed to call the doc and then it breaks), aches, doesn't want to eat alot, doesn't want to do anything, etc. etc. I don't know whether this is normal for this or not -- mom is confused and can't remember her facts right and hasn't been able to for some time now -- I keep checking on things and I am just about to "explode" in this: how can I make sure she gets the best care she may need here?????? I know this is buried in a topic area that probably is way not appropriate or helpful; is OK to PM me on this (gradually I am getting familiar with all the "perks" of this bboard and how to use them) -- all I want to do is know how to stay "one step ahead" and protect my mom against things that can be prevented by what is known in the world so far; the doctors aren't helping me much in that area and my mom isn't strong in wanting to help herself.......all I want to know is how to help her the best way I can. I don't mind being a doctor's worst nightmare as long as my mom gets the best treatment options possible (she deserves that). I hope I didn't sound "witchy" to you guys, no.... wasn't my intent: you guys are wonderful and offer the best hope and information I've got to go on...I just don't know how really to become "informed" to help my mom more. Shedding some tears as I wrote this, Linda Quote Link to comment Share on other sites More sharing options...
karen335 Posted March 13, 2006 Share Posted March 13, 2006 Linda, Just know we are here to help you. Just want you to be aware of reality and have some knowledge to question what your mom may endure during her fight. I didn't mean to make you sad or cry. I thought you were a nurse, sorry. This is a tough time, the beginning of the road. Sounds like your mom is a fighter, she will be fine, just keep a positive attitude. Come here often and ask questions, we may not have all the answers, but we will help you find them.. Hugs, Karen Quote Link to comment Share on other sites More sharing options...
gpawelski Posted September 1, 2006 Author Share Posted September 1, 2006 Emerging data is showing that there is a continuing problem with the Chemotherapy Concession. A system which rewards medical oncologists for being pharmacists. The kaisernetwork.org's Daily Health Policy Report lists two recent New York Times articles that indicate this is precisely how chemotherapy drugs are being selected in the real world of cancer medicine. After the last seven years of investigating this myself, it doesn't really surprise me. But the lastest Times articles have surprised me! Federal laws bar drug companies from paying doctors to prescribe medicines that are given in pill form and purchased by patients from pharmacies. But companies can rebate part of the price that doctors pay for drugs which they dispense in their offices as part of treatment. Doctors receive the rebates after they buy the drugs from the companies. But they also receive reimbursement from Medicare or private insurers for the drugs, often at a markup over the doctors' purchase price. And the revelation about pharmaceutical companies calculating to the penny the profits that doctors could make from their drugs and sales reps from those companies shaing those profit estimates with doctors and their staffs. This information comes from industry documents that have become public in a federal civil lawsuit against the drug makers. This documents show that representatives for the companies actually brought spreadsheets to oncologists' offices to show doctors how much they could make. http://www.kaisernetwork.org/daily_repo ... R_ID=45527 http://www.healthyskepticism.org/news/2007/Jun.php The cancer industry derives most of its profits from chemotherapy. Both the drug companies and the treatment providers profit from the chemotherapy drugs and the medications used to combat the side effects. The obscene profits made off chemotherapy override any incentive to find a cure or better treatments. Doctors administer chemotherapy in their offices, buy the drugs at a lower cost than what insurance companies and public health care programs pay and pocket the difference. This system provides an incentive to overuse chemotherapy and the most expensive medications. http://www.lawyersandsettlements.com/ar ... eruse.html Let's take medical oncologists out of the retail pharmacy business and force them be doctors again. Quote Link to comment Share on other sites More sharing options...
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