Chemotherapy Drug Concession

[gpawelski]

Oncologists long avoided cuts forced on other specialists because the government allowed them to bill Medicare for cancer drugs in amounts that often far exceeded their actual costs. Even the American Society of Clinical Oncologists say, "we did not like the old system, even the perception that it set up inappropriate incentives we did not support." Some studies suggest that American oncologists overuse cancer drugs, particularly in the last months of patients' lives after the patients have failed to respond to treatment. Advocates for cancer patients say that Medicare's reimbursement system encouraged overtreatment.

On average, oncologists in private practice made $310,371 in 2002, according to surveys by the Denver-based Medical Group Management Association. Where does the bulk of a private oncologist's income come from? The Journal of the National Cancer Institute (JNCI) commented that office-based oncology practices typically derive two-thirds of their income from selling chemotherapy" (JNCI 2001;93:491). The practices are compensated both for delivering the drugs and for the drugs themselves.

The new (MMA) system still has major flaws, in that it continues to provide incentives to administer chemotherapy, in the same way that surgeons have a financial incentive to recommend surgery. Additionally, it is a certainty that there will be large differences between the profit margins of administering different drugs, providing continuing incentives to base drug selection on profit margin. However, the new system is clearly an improvement from the standpoint of cancer patients, taxpayers, and advocates of basing drug selection on individual tumor biology, rather than on a least common denominator approach which invites conflict-of-interest medical decision-making."

What this shows is that simply reducing reimbursement for drugs isn't the answer to the biggest problems, which are financial incentives for infusion therapy over oral therapy or non-chemotherapy, and financial incentives for choosing some drugs over others. One example, oncologists will just not give gemcitabine and /or irinotecan, but instead will choose drugs which are profitable.

Oncologists should simply submit copies of their drug invoices and get paid the exact cost of the drugs, plus only a small markup for administrative expenses. They should get reimbursed for the costs of actually adminsitering the drugs, plus a small markup which is not enough of an incentive to treat with infusion therapy, rather than just writing a prescription for drugs which would be filled at a pharmacy.

Office-based oncology practices derive most of their revenues from treating patients with chemotherapy. The practices are compensated both for delivering the drugs and for the drugs themselves. The Journal of the National Cancer Institute (JNCI) states that private-practice oncologists typically derive two-thirds of their income from selling chemotherapy.

Reimbursement of any kind is often lacking with oral-dose drugs because the patient purchases them directly. The oncologist simply writes a prescription and the patient goes to a pharmacy and obtains the product. There are no administration fees for office-based oncology practices unless they also dispense the drugs, because there is no involvement in their purchase.

The practice will realize almost no revenue from those patients who are treated entirely with oral-dose agents. The core activity in medical oncology is the provision of infusional chemotherapy. The entire structure of office-based practices revolves around this activity and is what distinguishes medical oncology from most other specialties.

Oral-dose chemotherapeutic agents are easy to use and offer the promise of less frequent visits to the physician's office and their infusion rooms. This promise is not trivial, especially as we have come to realize that many forms of cancer may be managed with these drugs, especially when they offer the equivalent outcome as intravenous drugs.

The fact that medical oncologists receive no reimbursement for providing oral-dose therapy to patients had been the principal barrier to the availability of oral-dose protocol. The advent of oral agents ultimately means that medical oncology will need to change its identity, prior to the chemotherapy drug concession.

Under the new Medicare Bill (MMA) medical oncologists will be reimbursed for providing evaluation and management services, making referrals for diagnostic testing, radiation therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival.

Because oral-dose drugs ultimately deliver on their promise of combining equally efficacious therapy with better adverse event profiles and easier administration, they will rightfully gain their appropriate share of the marketplace, again.

What needs to be done is to remove the profit incentive from the choice of cancer treatments. Patients should receive what is best for them and not what is best for their oncologists. Then, perhaps we can stop giving patients needless chemotherapy that spreads cancer cells, rather then telling cancer patients that the cancer came back or is spreading on it's own.

[Donna G]

Gregory, where did this article come from? Is this your opinion?

Chemo therapy is life saving. Much has been done in recent yrs that has lowered the cost of administering chemo. I remember when chemo was only given by the doctor, in a hospital bed and the patient required a lot of care before and after! Now is is usually given in a matter of hours , as an out patient, and meds such as Zophran usually keep nausea etc under control so you can sleep at home!. The varietty of meds available now compared to 20+ yrs ago is amazing. Many people do take oral chemo if it will help them. Could you post where this article came from? Donna G

[gpawelski]

The American Society of Clinical Oncologists (ASCO) says oncologists should make chemotherapy treatment recommendations on the basis of published reports of clinical trials and a patient's health status and treatment preferences.

So what about those published reports of clinical trials?

More chemotherapy is given for breast cancer than for any other form of cancer and there have been more published reports of clinical trials for breast cancer than for any other form of cancer.

According to the National Cancer Institute’s March 31, 2006 official cancer information website on "state of the art" chemotherapy for recurrent or metastatic breast cancer, it is unclear whether single-agent chemotherapy or combination chemotherapy is preferable for first-line treatment. At this time, no data support the superiority of any particular regimen. So, it would appear that published reports of clinical trials provide precious little in the way of guidance (1).

In the total absence of guidance from published reports of clinical trials then, what basis are treatment regimens selected instead? ASCO says that this should be further based on a patient's health status and patient treatment preferences.

So what is being done?

Recently published in the journal Health Affairs is a joint Harvard/Michigan study entitled, "Does reimbursement influence chemotherapy treatment for cancer patients?" The authors documented a clear association between reimbursement to the oncologists for the chemotherapy of breast, lung, and colorectal cancer and the regimens which the oncologists selected for the patients. In other words, oncologists tended to base their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist (2).

A March 8, 2006 New York Times article described the study. One of the more interesting aspects of the story was a comment from an executive with ASCO, Dr. Joseph S. Bailes, who disputed the study's findings, saying that cancer doctors select treatments only on the basis of clinical evidence (3).

So ASCO's Dr. Bailes maintains that drugs are chosen only on the basis of "clinical evidence."

Yet Dr. Neil Love reported a survey of breast cancer oncologists based in academic medical centers and community based, private practice medical oncologists. The former oncologists do not derive personal profit from the administration of infusion chemotherapy, the latter oncologists do derive personal profit from infusion chemotherapy, while deriving no profit from prescribing oral-dosed chemotherapy.

The results of the survey could not have been more clear-cut. For first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists (who are motivated to keep off-protocol patients out of their chemotherapy infusion rooms to reserve these rooms for on-protocol patients) 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 commuity-based oncologists, only 18% prescribed the non-remunerative oral-dose drug (capecitabine), while 75% prescribed remunerative infusion drugs, and about 40% prescribed the expensive, highly remunerative drug docetaxel (4).

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 (5).

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.

It's not that all oncologists are bad people. It's just that it is still 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.

Sources:

(1) http://www.cancer.gov/cancertopics/pdq/ ... ection_297

(2) http://content.healthaffairs.org/cgi/co ... t/25/2/437

(3) http://www.nytimes.com/2006/03/08/healt ... de&ei=5070

(4) http://patternsofcare.com/2005/1/editor.htm (figure 37, volume 2, issue 1, 2005)

(5) http://www.positivehealth.com/test/articles.asp?i=1832

[Elaine]

I am not sure you addressed Donna's questions and concerns. One thing to note is that while there are new oral dose therapies, most medicare patients will not have these covered until the year 2006. Further, uninsured, under insured and people, like me, without prescription coverage but who do not earn a little more than a poverty level income are not eligible for these drugs. Thus, in some ways, these newer therapies again draw lines and thus create another set of haves and have nots. It can't be said enough times that the fact that such discrepencies exist in this country is abominable.

A capitalistic economy does not have to include discrepancies in health care.

elaine

[gpawelski]

Oncologists are among the most highly-paid of the internal medicine sub-specialties. Office chemotherapy has made thousands of oncologists not just prosperous but rich. Office chemotherapy has served as an incentive to overtreat with infusion chemotherapy and to encourage the patient to receive 2nd, 3rd, and 4th line chemotherapy, regardless of the likelihood of meaningful benefit.

The system creates a hopeless conflict of interest, in that certain forms of chemotherapy are much more remunerative than others. ASCO and other fraternal organizations have never felt the need to perform clinical trials to determine whether or not treatment outcomes and patient satisfaction are altered by profit incentives.

The much needed reforms to the system, which are currently ongoing, are occurring over the fight to the death opposition of a profession which is vastly more concerned with protecting the selfish monetary interests of its members than in promoting the well-being of its patients.

The new medicare bill virtually changes nothing. If anything, it's worse. The only thing it does is to give the government a little bit of protection against being egregiously gouged on individual drugs. It doesn't change the basic incentives to give chemotherapy, whether or not chemotherapy is in the best interests of the patient, and to base drug selection on the "spread" between reimbursement and cost, which will continue to differ marketly between different drugs.

The law requires drug manufacturer's to provide quarterly reports of "actual average" sales costs. Average sales costs do not include prices to hospitals, HMOs, government entities, etc., it only includes prices actually charged physicians. Reimbursement level is this average selling price plus 6%, except if the oncologist documents that he/she actually had to pay more than the official reimbursement rate, he/she will then be reimbursed for his/her actuall cost.

In addition, the oncologist will be reimbursed for all bad debt, including uncollectible deductibles and co-pays. They will be reimbursed for associated drug administration services, chemotherapy support services, physician "supervision" time, and so on, and so forth. Thus, the oncologist remains incentivized to treat, rather than counsel, and they are incentivized to treat with certain "deal of the month" drugs.

It is illegal for physicians to refer patients for laboratory studies to centers in which they hold a financial interest. This is a sensible regulation against self-referral for perhaps unnecessary services which remunerate the referring physician, who then becomes the providing physician. The ideal would be if patients received chemotherapy at some treatment center which wasn't involved in the decision to treat or not to treat and in which the oncologist didn't have a financial interest.

There is no proven "standard" first line therapy which has been shown to be superior to the many other choices which exist. The same situation exists in the setting of 2nd, 3rd, 4th line therapy. The therapies are equivalent on a "population" basis, but not on an "individual" basis. Proven by the large number of patients who have progressive disease on 1st line therapy but who have good responses to 2nd or 3rd line therapy. These patients should have received the "correct" treatment in the first line setting. This can be accomplished by individualizing cancer treatment based on testing the cancer biology.

[gpawelski]

Report: Doctors' $275M Study Questioned

By KEVIN FREKING

The Associated Press

Tuesday, August 29, 2006

http://www.boston.com/yourlife/health/a ... uestioned/

In 2005, CMS initiated a one-year demonstration project for cancer patients undergoing chemotherapy. The demonstration focused on measuring patient outcomes in three areas of concern often cited by patients undergoing infusional chemotherapy: controlling pain; minimizing nausea and vomiting; and reducing fatigue. Oncology Practices reporting data on all three factors qualified for an additional payment of $130 per encounter for chemotherapy administration (a financial incentive to use infusional drugs over oral drugs). That included a $26 patient copay.

A Republican, Senate Finance Committee Chairman Chuck Grassley, found out from the Health and Human Services' inspector general's office that the value of the approximately $300 million-a-year demonstration project to report this information was for nothing. Providers were being paid $130 to simply forward the data that was already collected.

While a Michigan/Harvard study (before Medicare reforms) documented a clear association between reimbursement to oncologists for the chemotherapy and the regimens which oncologists select for their cancer patients, a "Pattens of Care" study (after Medicare reforms) showed results that Medicare reforms are still not working. It is still an impossible conflict of interest. Once a decision to give chemotherapy is taken, oncologists receiving more-generous Medicare reimbursements used more-costly treatment regimens.

According to findings in the American Medical Group Association's 2005 Medical Group Compensation & Financial Survey, most specialties saw modest increases in compensation in 2004. The majority of specialties experienced increases at or just above the rate of inflation, and the primary care specialties saw increases of 6% - 8.8%.

The survey found that during 2004 three specialties experienced the largest increases in compensation: general surgery (8.89%), pediatrics & adolescent (8.76%), and hematology & oncology ($8.52%). In addition to pediatrics and adolescent, other primary care specialties saw increases: family medicine (6.31%) and internal medicine (7.57%).

Medicare Cancer Project Scrutinized

While doctors profited, patients paid for study about chemotherpy

By Lisa Myers

Senior Investigative Correspondent

NBC News Investigative Unit

http://www.msnbc.msn.com/id/15320188/

[gpawelski]

Two recent studies documented that their chemotherapy concession of the last twenty years, reeked of corruption. A joint Michigan/Harvard study 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 based their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist.

The study added to the 'smoking gun' Patterns of Care survey. 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.

http://content.healthaffairs.org/cgi/co ... t/25/2/437

http://patternsofcare.com/2005/1/editor.htm (figure 37, volume 2, issue 1, 2005)

[karen335]

GD,

This information is greatly appreciated. Your research and findings are greatly apprecieted. Please keep us informed. It seems I can relate very much to this information.

Karen

[gpawelski]

Karen

When I have material that is pertinent, breast, lung and ovarian (a.k.a. adenocarcinoma) cancers, and it is fact checked by oncologists, then I post it. There is some exciting things coming down the line, some technologies are already present but not totally accepted by the powers that be. Gene Expression assays (to predict the likelihood of cancer recurrence), Pharmacogenomic testing (identify toxicity of drugs), and Chemotherapy Sensitivity and Resistance assays (testing for drug activity against a tumor). These three are so complementary to each other. The fastest way to improve things is to match treatment to the patient, like these technologies are capable of.

My wife had chemotherapy in 1972, and then again in 1997. The "before" and "after" of the chemotherapy drug concession. "Before," she took it with relative ease. The postoperative drug she took, Chlorambucil (Leukeren) is among the slowest acting and least toxic of the alkylating agents (well tolerated oral drugs). Depression of the immune system was slow and reversible, allowing it to regenerate and contribute to recovery. A malfunctioning immune system can fail to stop the growth of cancer cells. She went twenty-four years before experiencing any recurrent cancer.

She could not believe what happened "after." Infusion-therapy, given in big doses, with breaks of several weeks between doses to let the body try to recover (or else it can kill a patient). The effectiveness of her combination regimen was limited because of the late stages of her recurrent cancer and most patients develop resistance. Most cancer patients have the drug bounce off their tumors, doing little if any good.

I look forward to the day that "infusion" therapy goes by the way of the Neanderthal.

[endangered but surviving]

thanks for the info ans source: Patterns of care.

thanks again,

joyce

[gpawelski]

All over-the-counter drugs you purchase at the pharmacy, have dosage, usage and side-effect declarations on the label. Even prescription drugs that are purchased from a pharmacy have print-out and/or labels. It has been brought to my attention, under the concept of the Chemotherapy Drug Concession, the oncologist's office (except for some urologists) is the only place you can buy drugs that are not labeled.

This means that "informed consent" is the only thing close to "labeling" of these chemo agents. Numerous oncologists have been playing fast and loose with "informed consent," many times ignoring it in spite of the fact that doing so is against the law. Without the proper administration of "informed consent" or consultation, the patient receiving receiving chemotherapy is less informed than a person purchasing and using a package of Tylenol or Benadryl.

Another way of looking at it is that not only does the oncologist have complete logistical, administrative, marketing and financial control of the process, he/she also controls the "knowledge" of the process. This amounts to total control. In economic terms, it would be in violation of the antitrust laws. The result is that the oncologist selects the product, selects the vendor, decides the markup, conceals details of the transaction to the degree he/she wishes, and delivers the product on his own terms including time, place and modality.

Anyway, January 1, 2006, beginning the Change of Medical Oncolgoy under Medicare, senior Americans with cancer may not even have to go to hospitals, let alone the infamous infusion-rooms of office-based oncology practices. That's because the new Medicare Modernizaton Act will offer them benefits they did not have before, such as coverage for oral chemotherapy drugs. If prescribed an oral-dose chemotherapy drug, you will be given a prescription that you will take to your local pharmacy to have filled, just like you normally do with all the other prescription medications that you may be taking. Because it is a pill, patients can take it at home with only occasional visits to the doctor or clinic.

Oral chemotherapy drugs are treating cancer effectively and enhance the quality of treatment for cancer. Compared to infusional therapy, oral-dose cancer drugs can make treatment more convenient for patients by allowing flexibility, without disrupting work or other activities. Taking your medication at home allows you the freedom to carry on with your daily life. This results in less time spent in hospitals and private oncology practices because of the absence of intravenous administration and its related side-effects.

These targeted cancer therapies will give doctors a better way to tailor cancer treatments. Treatments may be individualized based on testing the individual properties of each patient's cancer. These new differences in therapy hold the promise of being more selective, harming fewer normal cells, reducing side-effects, and provide a savings in health care costs.

If you have a private health plan which has a good prescription plan, how goes medicare, goes most private pay plans. If you want to apply for the new Medicare prescription benefits, you may do that also. Oral chemotherapy will be handled the same as "infusion" chemotherapy by Medicare. However, if you can and want to utilize a lot of the generic or older drug agents, the cost would be significantly less.

[Donna G]

I have found many many hits on the web where you have posted your information. These state you have done lots of research. I can see that your loss of your wife who originally had Ovarian cancer was very difficult for you.

http://www.cancerlynx.com/pawelski.html

This post goes back to 2002

What is your profession? Concerning oral chemo better than IV, you are the only one that comes up doing a google search, who makes these blanket statements.

I respect the fact that you have been motivated by your loss but I still would want to read that others, as Onocologists in the teaching centers are researching and finding the results you speak of.

Again, I am sorry for your loss. Donna G

[gpawelski]

Thank you for posting the link for CancerLynx, who asked for permission to post that essay back then. They are an online zine for cancer patients and professionals. There are multitudes of very fine web sites that talk about oral chemotherapy. These are the new "targeted" cancer therapies you hear and read about that give doctors a better way to tailor cancer treatment. Treatments may be individualized based on the unique set of molecular targets produced by a patient's tumor.

The director of NCI, Dr. Andrew C. von Eschenbach, picked to be the new acting chief of the FDA, was quoted in the media believing that while now, doctors treat illnesses based on how well other people have responded to a given treatment, soon they will tailor response built around specific understandings of the patient, the treatment and the disease. "We are discovering so much about diseases like cancer at the molecular level," he says, "which will lead us to a new kind of health care." He feels much of what has been done, has been based on a model of "empiricism." He goes on to say, "doctors will be able to intervene with medical treatments more effectively matched to a specific patient's illness." One of his main goals is to prepare the FDA for this transformation.

There is a need for changes in our approach to the chemotherapy of the most common forms of adult cancers. Patients are given more aggressive chemotherapy by utilizing combinations, high dose therapy, etc, in diseases like metastatic breast, lung and ovarian cancer and you increase response rates (which is tumor shrinkage, not cure), but you don't improve overall survival. The true situation is that ineffective, aggressive chemotherapy can diminish not just quality of life but also quantity of life, through organ toxicity, immunosuppression, and inducing genetic mutations.

You may want to reserve aggressive therapy for those patients who will derive more benefit than harm, while identifying the most promising treatment regimens for everyone. In patients with tumors very resistant to cytotoxic chemotherapy in general, the most promising treatments may include angiogenesis inhibitors, growth factor inhibitors, or more integrative holistic therapy approaches.

A better approach may be not to give more aggressive and toxic and mutagenic and immunosuppressive combinations, but to give targeted single agents, or to give the least toxic and mutagenic "active" combinations. We should put much more emphasis on matching the treatment to patient, though the use individualized testing, have more respect for minimal partial response or stable disease, when it can be achieved through the use of the least toxic and mutagenic drug regimens, and reserve the use of higher dose therapy or agressive combination chemotherapy to those fortunate patients with tumor biologies most amenable to attack and total or near-total destruction by these aggressive treatments.

What a cancer patient would like ideally, is to know whether they would benefit from adjuvant chemotherapy. If so, which active drugs have the highest probability of working and are relatively non-toxic in a given patient.

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.

[gpawelski]

Selling cancer chemotherapy with concessions creates conflicts of interest for oncologists

The shift in the United States, 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 Coverage Advisory Committee meeting in 1999, in Baltimore, Maryland. 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 (1).

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 entitled, "Does reimbursement influence chemotherapy treatment for cancer patients," (2) confirmed that before the new Medicare reform, medical oncologists are more likely to choose cancer drugs that earn them more money. A survey by Dr. Neil Love, published in "Patterns of Care," showed results that the Medicare reforms have not solved the problem of variations in oncology practice(3).

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. Social science research shows that people can be biased by self-interest without being aware of it.(4) 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 U.S. government wasn't reducing payment for cancer care under the new Medicare Modernization Act (MMA) of 2003. 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 (5).

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.

It's not that all oncologists are bad people. It's just that it is still an impossible conflict of interest (i.e. it's the SYSTEM which is rotten). The solution is not to put the doctors in jail; it's to change the system. (6)

1. Verbatim Transcript of Medicare Coverage Advisory Committee (MCAC) Meeting, November 15-16, 1999.

http://weisenthal.org/hcfa_1.htm

http://weisenthal.org/hcfa_2.htm

http://weisenthal.org/hcfa_3.htm

2. Jacobson M, O'Malley AJ, Earle CC, Pakes J, Gaccione P, Newhouse JP. Does reimbursement influence chemotherapy treatment for cancer patients? Health Aff (Millwood). 2006 Mar-Apr;25(2):437-43.

http://content.healthaffairs.org/cgi/co ... t/25/2/437

3. Love N. Editor's Note: Phase I study of the "gap". Patterns of care in medical oncology. 2005; 2(1)

http://patternsofcare.com/2005/1/editor.htm

4. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA 2003 Jul 9;290(2):252-5

http://jama.ama-assn.org/cgi/content/full/290/2/252

5. www.medicare.gov

6. Pawelski GD. Reimbursements Sway Oncologists' Drug Choices. Online Journal of Health Ethics 2006;1(1)

http://ethicsjournal.umc.edu/ojs2/index ... sue/view/4

[gpawelski]

The Health Affairs article (1), given play in The New York Times (2), showed that the prescribing behaviors of oncologists caring for Medicare patients between 1995 and 1998 were influenced by the lucrative economics and their drug retailing arrangements. The study's investigative team was comprised of prominent researchers, including a Dana-Farber oncologist. When interviewed, the investigators were emphatic that the study found strong links between oncologists' financial interests and their clinical decisions.

And while the Harvard/Michigan study published in Health Affairs showed results before the new Medicare reform, the Patterns of Care study showed results that the Medicare reforms are still not working (3).

Few healthcare professionals outside the oncology community were surprised. It is common knowledge that most oncologists integrate drug revenues into their practices to bolster their incomes.

The apparent importance of the findings notwithstanding, the Community Oncology Alliance (COA) flatly rejected the news (4). COA released an e-mail bulletin, "The Remarkable Story of Community Oncology," just after the articles broke. The opening sentence called the study's findings "incredibly outrageous and unsubstantiated" and "an unbelievable rehash." Sentence two referred to "incomprehensible statements by government bureaucrats, so-called oncology advocates, well-paid consultants, non-practicing physicians, payers, and specialty pharmacies." In other words, COA cast aside the study, presumably because critics cannot appreciate oncology's complexities and because they are almost certainly misguided or harbor malevolent intent.

Not Acceptable

There are many reasons why this kind of reaction is unacceptable, but the most obvious is that there appears to be a real problem here. The study's investigators are reputable, the journal is credible, and the findings are damning. True, the data were as much as a decade old and from Medicare patients only, but the practice in question - oncologists' prescribing decisions being altered to optimize drug revenues - is still widespread. There is little reason to believe that another analysis with updated data would obtain a different result.

But COA protested too much. It refused to admit that the practice represents a potential conflict. It claimed that community oncologists provide the "highest quality care" but failed to offer data in support of that statement. Ultimately, it avoided the issue entirely, deflecting attention to other, more praiseworthy aspects of oncology practice. And it ridiculed the credibility of the professionals who broached the issue.

To the non-oncologist, such a dismissive response is viewed as self-serving and protectionist. It demeans oncologists' important work and confirms critics' suspicions that an unsavory but hidden practice is ongoing. But worse, it suggests a higher regard for financially rewarding drug arrangements that for patient quality of care. An appropriate response might have soberly acknowledged the findings. It would have then refuted those findings with other data, or committed to addressing the issue.

Getting Serious

There are serious issues that demand serious responses. The American health system is rapidly approaching wholesale collapse due to exploding costs, in large measure because a lack of transparency has created a culture of opportunism and waste exploited by groups throughout the continuum of supply, care, and finance. The Health Affairs article suggest that community oncology is squarely part of the problem.

In the interests of transparency and the reputations of its practitioners, community oncologists should immediately develop a response to the concerns raised by the article. You should release data on:

- the prevalence of the practice of oncologists profiting from the drugs they prescribe;

- the markups involved, and how those revenues translate to income;

- oncologists' adherence rates to evidence-based chemotherapy guidelines; and

- differences in the practice patterns of oncologists who do and do not financially benefit from the drugs they prescribe.

You should follow this information with proposed guidelines to resolve potential conflicts between clinical practice and financial incentives.

Providing Leadership

More than any group, physicians lay claim to a higher purpose and so must also provide the leadership that can help reestablish trust in our doctors and a more effective healthcare system. Community oncologists can and should provide that leadership.

You could advocate for and implement pricing transparency in oncology drug treatment. As Jerry Reeves, MD, urged in a recent interview (5), the charges to patients and other payers should be transparent and open, not hidden. And conflicts of interest should be avoided.

Of course, oncologists should be paid fairly for the services they provide. Continuing to work with Medicare and private payers, you should aim to transition practices away from indirect drug revenues and replace those with higher direct fees for professional services.

As Dawn Holcomb (6) and Linda Bosserman (7) argued last year in this journal, you could lead an effort to develop data on clinical outcomes and cost that can drive future practice and policy change. You could accelerate positive change within your profession by encouraging incentives for patients to choose doctors who have demonstrated care that is safer, more effective, and more efficient.

Anything less will be merely protecting the interests of oncologists over the interests of patients.

References

(1) Jacobson M, O'Malley AJ, Earle CC, Pakes J, Gaccione P, Newhouse JP. Does reimbursement influence chemotherapy treatment for cancer patients? Health Affairs 2005;25:437-443.

(2) Abelson R. Pay method said to sway drug choices of oncologists. The New Your Times March 16, 2006.

(3) Patterns of Care, Volume 2, Issue 1, 2005

(4) Community Oncology Alliance. The remarkable story of community oncology [news-letter].March 16, 2006.

(5) Klepper B. The new focus on accountability [interview with Jerry Reeves, MD]. Commun Oncol 2006;3:241-243.

(6) Holcomb DG. Is oncology compatible with specialty pharmacy? Commun Oncol 2005;2:173-181.

(7) Bosserman L. Specialty pharmacy and MVI:ill-advised systems, wasteful, and harmful [editor's note]. Commun Oncol 2005;2:178-180.

Community Oncology Vol 3/Num 7: Having Your Say July 2006

Center for Practical Health Reform