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Mireille Jacobson, A. James O’Malley, Craig C. Earle, Juliana Pakes, Peter Gaccione, and Joseph P. Newhouse Does Reimbursement Influence Chemotherapy Treatment For Cancer Patients? Health Affairs, March/April 2006; 25(2): 437-443. [Abstract] [Full Text] [PDF] [Technical Appendix] [Reprints & Permissions]

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Electronic letters published:

Reimbursements Sway Oncologists' Drug Choices

Gregory D. Pawelski   ( 15 March 2006 )

Selling Cancer Chemotherapy With Concessions Creates Conflicts Of Interest For Oncologists

Gregory D. Pawelski   ( 1 August 2007 )

Reimbursements Sway Oncologists' Drug Choices 15 March 2006
Gregory D. Pawelski, Retired Send letter to journal: Re: Reimbursements Sway Oncologists' Drug Choices gdpawel{at}attglobal.net Gregory D. Pawelski	The joint Michigan/Harvard study confirms medical oncologists choose cancer chemotherapy based on how much money the chemotherapy earns the medical oncologist. This study adds to the "smoking gun" study of Dr. Neil Love ("Patterns of Care") on the subject.[1] The results of his survey show that for first-line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists 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, only 18% prescribed the oral dose drug (capecitabine), while 75% prescribed infusion drugs, and 29% prescribed the expensive, highly remunerative drug docetaxel. 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. Once a decision to give chemo is taken, physicians receiving more-generous Medicare reimbursements used more-costly treatment regimens. What was interesting about the "Patterns of Care" study was that it is contemporary, after the Medicare reform. It shows that the Medicare reforms haven't solved the problem. It's not that all oncologists are bad people. It's just an impossible conflict of interest, it's the system which is rotten. The solution is to change the system. So far, Medicare reform hasn't achieved that. Two scientific, "evidence-based" studies giving a dose of reality. NOTE 1. http://patternsofcare.com/2005/1/editor.htm
Selling Cancer Chemotherapy With Concessions Creates Conflicts Of Interest For Oncologists 1 August 2007
Gregory D. Pawelski, Retired none Send letter to journal: Re: Selling Cancer Chemotherapy With Concessions Creates Conflicts Of Interest For Oncologists gdpawel{at}comcast.net Gregory D. Pawelski	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, multispecialty 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. The joint Michigan/Harvard study published in Health Affairs, to which I'm writing in response, 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, produced results showing that the Medicare reforms have not solved the problem of variations in oncology practice.(2) 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 poses 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.(3) 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. It was 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 allowed to be doctors again. The solution is not to put the doctors in jail; it's to change the system. (4) Notes 1. Verbatim Transcript of Medicare Coverage Advisory Committee (MCAC) Meeting, November 15-16, 1999. Volume I, Volume II, Volume III 2. 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 3. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA 2003 Jul 9;290(2):252-5 4. Pawelski GD. Reimbursements Sway Oncologists' Drug Choices. Online Journal of Health Ethics 2006;1(1) http://ethicsjournal.umc.edu/ojs2/index.php/ojhe/issue/view/4