Changing the Identity of Medical Oncology Under Medicare

[gdpawel]

Selling cancer chemotherapy with concessions creates conflicts of interest for oncologists

Emerging data is showing that there is a continuing problem. A system which rewards medical oncologists for being pharmacists. Choosing drugs for cancer patients based on profits to the medical oncologist. These articles indicate that this is precisely how chemotherapy drugs are being selected in the real world of cancer medicine

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.

http://www.healthyskepticism.org/news/2007/Jun.php

[gdpawel]

A recent article published by the National Institute of Health concluded that "about one fourth of abstracts at American Society of Clinical Oncology (ASCO) Annual Meetings have an author with a personal financial interest." Since many of these abstracts are about the results of clinical studies, this means that the study results are being penned by authors that may have a "personal financial interest" in the outcome.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17704409&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Attitudes toward research participation and investigator conflicts of interest among advanced cancer patients participating in early phase clinical trials.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17687154&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

These two articles touch on a critical subject - when an oncologist recommends a treatment the reason behind the recommendation may be complex. It can be a result of the doctor's training and experience in combination with the investments made by the hospital or the doctors own research interests or their financial relationships with various outside entities. In short, a patient and their family must be their own best advocate and get at the heart as to why a specific treatment regimen is being suggested. Don't be afraid to ask questions to make informed treatment decisions!

Cancer treatments 'excessive'

Cancer sufferers are taking doses of expensive and potentially toxic treatments that are possibly well in excess of what they need, medical oncologist Dr. Ian Haines reported in the Journal of Clinical Oncology. Emerging evidence shows that many of the highly expensive "targeted" cancer drugs (Herceptin, Avastin and Rituximab) may be just as effective and produce fewer side effects if taken over shorter periods and in lower doses.

He stated in the Journal that "it would seem that pharmaceutical companies are attracted to studies looking at the maximum tolerated dose of any treatments." He suggested the we make the search for minimum effective doses of these treatments one of the key goals of cancer research.

He gave as an example, Avastin, used to fight colon and lung cancers, the dose being tested is 15 milligrams per kilogram of body weight, despite other research showing it may work with 3 milligrams per kilogram.

A study published in the journal of the American Cancer Society, led by Jeffrey Peppercorn of the University of North Carolina Lineberger Cancer Center, along with three researchers at the Dana-Farber Cancer Institute, found that 84% of trials with pharmaceutical-company involvement showed positive results, compared to 54% for trials without industry backing. Another previous study in oncology, looking at multiple myeloma, found that pharmaceutical studies reported positive results in 74% of trials compared to 47% of non-industry-sponsored trials.

An increasing number of drug studies are developed through collaborations between academic medical centers and drug companies. In fact, pharmaceutical-industry investment in research exceeds the entire operating budget of the NIH. It is important to understand the influence that industry involvement may have on the nature and direction of cancer research. Studies backed by pharmaceutical companies were significantly more likely to report positive results.

As the Haines study suggests more must be spent on analyzing drug data, we also need larger and more detailed studies to figure out why there is an association between pharmaceutical involvement and positive results. Some of the connection between industry and positive results may be because industry focuses on drug development and they do it well.

However, drugmakers are going directly to the consumer at a time when their products are indeed at the margins of evidence-based medicine. On one hand, pharmaceuticals advertise extensively and the advertising is manipulative in the extreme. On the other hand, even NCI-designated cancer centers do this sort of direct to consumer, hard sell advertising. And in cancer medicine, the media advertising is no more misleading than the one-on-one communication which often goes on between a chemotherapy candidate and an oncologist.

A Karolinska Institute in Sweden study showed that U.S. health care system is good at delivering expensive drugs, but that our health care system is not so good at simple medicine like preventive care. Our pharmaceutical-based health care system is very good at creating new health care products that will make a lot of money, but it it's something that has no chance of profit, forget it.

It doesn't take a rocket scientist to figure out that the United States does a good job of developing and delivering new and expensive drugs to cancer patients, because that is the only thing we're good at. But it'll take a rocket scientist to figure out how this makes for a better health care system.

http://jco.ascopubs.org/cgi/content/full/25/25/e31

[gdpawel]

Cancer Drug Representatives Spelled Out the Way to Profit

"It's clear that physicians stopped making decisions based on what made scientific or clinical sense in lieu of what made better business sense"

Medicare's decision to reform the way it paid for cancer drugs came after a decade in which oncologists collectively made billions of dollars on the drugs they prescribed.

http://www.nytimes.com/2007/06/12/business/12cancerside.html?ref=business

Incentives Limit Any Savings in Treating Cancer

"The system doesn't value the time we spend with patients"

When Medicare cracked down two years ago on profits that doctors made on drugs they administered to patients in their offices, it ended a windfall worth hundreds of thousands of dollars a year for each ...

http://www.nytimes.com/2007/06/12/business/12cancerpay.html?_r=1&ref=health&oref=slogin

It's Still A Chemotherapy Concession

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.