Physicians

PHYSICIANS/PHARMA: The oncologists’ chemo junket flies above the radar

You may have heard just a few things on THCB from Greg Pawelski, Matt Quinn, me and others about the oncologist prescribing franchise, and how it might just change physicians’ behavior a tad. Well Greg informs me that last Thursday the whole issue made it onto the NBC Nightly News.

Greg also notes that the community oncologists (well, he calls them something rather ruder, but he’s insulting the world’s oldest profession so I won’t use his language) have their own response. They are “outraged!”

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  1. [I found out the above was written by Brian R. Klepper, PhD, President of The Center for Practical Health Reform.]
    I’m being accused by Dawn Holcomb of calling a spade (guess what?) a spade. Imagine that? The shift, some 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.
    Evidence-based medicine is the new refuge for robots whose batteries are dangerously low on power. It is much like a default function like “tilt” on a pinball machine. Why not let these robots do randomized trials to prove that patients aren’t harmed by built-in conflicts of interest with the choice of chemotherapy? What are they afraid of? Will it restrict their freedom of choice to prescribe drugs on the basis of their own self interests? Then the so-called respectible Journals (the ones that fail to adhere to guidelines on conflict of interest) can publish those studies, or will they not publish them because they have a lock-up on information?

  2. Prove that Community Oncologists Put Patients Before Profits
    A recent Health Affairs (1) article, 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.
    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 (3). 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 (4), 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 (5) and Linda Bosserman (6) 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) Community Oncology Alliance. The remarkable story of community oncology [news-letter].March 16, 2006.
    (4) Klepper B. The new focus on accountability [interview with Jerry Reeves, MD]. Commun Oncol 2006;3:241-243.
    (5) Holcomb DG. Is oncology compatible with specialty pharmacy? Commun Oncol 2005;2:173-181.
    (6) 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

  3. Medicare Coverage for Cell Culture Assays
    Favorable local coverage decision (LCD) regarding Medicare payment for Cell Culture Assay Test
    Cell culture assay technology has been clinically validated for the selection of optimal chemotherapy regimens for individual patients. It is a laboratory analysis based on tumor tissue profiling that uses fresh human tumor biopsy or surgical specimen to determine which drugs or combinations of chemotherapeutic agents have the highest likelihood of response for individual cancer patients.
    Individualized assay-directed therapy is based on the premise that each patient’s cancer cells are unique and therefore will respond differently to a given treatment. This is in stark contrast to standard or empiric therapy, which chemotherapy for a specific patient is based on average population studies from prior clinical trials.
    ASCO’s 2004 position paper focused on an older cell-growth assay method and not on a newer cell-death method, which is the most relevant biological measure. Their panel made no attempt to distinguish cell-death from cell-growth techniques. Their conclusions simply did not apply to cell-death assays. In fact, cell-death assay results have consistently correlated with response, time to progression, and overall survival.
    The ASCO paper focused solely on a lack of prospective, randomized clinical trials proving superior outcomes with assay-directed therapy, a standard not met by ER/PR testing, HER2 protein or gene analysis, or any other clinical test in cancer medicine, and has seldom been met by even the eimpiric chemotherapy treatments supported by ASCO. Were they to apply the standard measure of predictive test accuracy, the results of their analysis would have been much different and in favor of the use of cell-death assays in clinical practice.
    This omission was so significant that Medicare contractor, National Heritage Insurance Company which spent six months reviewing everything about the cell culture assay, including all of the ASCO arguments, and upon reviewing all available information, approved Medicare coverage for the tests as Oncologic in Vitro Chemoresponse Assays. They made the courageous decision to reverse trend and noted that the ASCO paper had failed the consider any of the many studies which support the predictive accuracy of cell death-based in vitro chemosensitivity testing.
    The decision had been made that the assay is a perfectly appropriate medical service, worthy of coverage on a non-investigational basis. What is of particular significance is that they are finally abandoning the artificial distinction between “resistance” testing and “sensitivity” testing and are providing coverage for the whole FDA-approved kit.
    Cell cuture assay tests based on cell-death have proven very effective in identifying novel treatment combinations for a variety of cancers. It is unfortunate that ASCO had not carried out studies to assess the value of cell-death assays, because they can and do accurately predict clinical outcomes and define novel chemotherapeutic synergies. In many cases, these same tests have induced highly durable remissions in patients whom current medical literature have deemed otherwise hopeless.
    Medicare coverage has been available for Chemosensitivity (Resistance) Testing for a tumor specimen from a Medicare patient obtained anywhere within the United States, but submitted for testing by one of the approved laboratories located within California.
    Source: http://www.medicarenhic.com/cal_prov/policies.shtml

  4. 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.

  5. Mr. Pawelski definitely shows a bias, and unfortunately a general misunderstanding of the process of cancer treatment and the payment system surrounding it.
    The payment process for drugs that has been recently overhauled, albeit still inaccurately within Medicare, was originally designed by the government and forced upon the oncologists. Numerous initiatives by both physicians and the government to adjust it over the years failed due to the recognition that cancer care was extremely complex AND that the current payment structure (which did pay about 20% more than the average cost of drugs) was actually subsidizing a fatal under-reimbursement system on the professional side.
    The basis for professional reimbursements was set in the early 1990s, back when there were few drugs available for administration in the office setting, and the volume in the office versus the hospital was low. As the costs of new drugs has increased in recent years and the costs and resources needed to manage diagnosis and delivery of cancer care grew more complex, the margin on drugs system to subsidize under-reimbursed professional costs no longer worked, and reform was needed and encouraged by physicians as well as payers.
    However, it is very easy to create a malicious soundbite based upon the old system that makes it look as though physicians are treating with higher cost drugs to increase margins. The reality that soundbite ignores is that physicians are treating with the most effective choices available to patients (as I’m sure any of us would wish for a loved one of ours with cancer), but those effective choices happen to be the newer drugs developed in recent years, which also happen to be the most costly. It almost turns into the vicious question that yields no acceptable answer “Are you still beating your wife?” The hundreds of oncologists with whom I have worked in the last decade across the country look at the patient and their treatment as an individual solution, and work with patients to determine what treatment, among many choices, best fits their disease and life. There are timing differences, administration differences, side effect profile differences, and even response rate differences…all of which must be factored into the equation. Now, there are pricing differences as well, as patients are asked by their employers and health plans to pay percentage copayments, difficult choices are being made. Some patients are even refusing certain care due solely to the cost. Physician practices are sensitive to the concerns of their patients, and have added staff to help patients work through these difficult decisions, none of which is reimbursed. It is an insult to the men and women who toil on a daily basis to help patients battle cancer – and who have, with the newer drugs now available, been able to turn most cancers into a chronic disease, rather than an automatic death sentence, – to now accuse them of solely choosing treatments for financial gain.
    Despite the inadequacies of the reimbursement for professional services, these community oncology practices (where 84% of all cancer care is now delivered) are able to support patients on a 24/7 basis, and deliver highly toxic treatments designed to kill human cells in a non-discriminatory manner, on an outpatient basis. Patients are able to return home to their lives and support systems now, instead of being relegated for weeks and longer to hospital beds. Significant side effects can now be managed to allow more dose dense treatments of the toxic chemotherapy agents. Side effect management allows patients to continue with more of their lives, in many cases, continuing to work and love and play, while battling their cancer. All this management takes an incredible amount of skill and resources in the community oncology office, but it is far more cost-effective than a hospital setting. There are dozens of non-reimbursable items not mentioned, all routine to cancer care, and without the ability to be rolled in to some overhead collectible dollar. These are expenses to the practice, along with the patient care providers that the practice never receives compensation for.
    What other industry do you know of that knowingly waits 60-90 days even longer, to be reimbursed for services and supplies for inventories mounting in the millions – even small oncology practices face drug inventories of that size? However, because oncology patient’s health status changes on a daily basis and drugs that were planned cannot be used as much as a quarter to third of the time, attempts to issue drugs on a prescription basis rather then through a physician’s single centralized inventory, would fail. We would actually add millions of dollars in wasted and unused drug to the nations health burden if oncology drugs were issued by prescription, because under most state pharmacy laws, once a drug has been issued in a patient’s name, if unused, that drug must be discarded and never reused or returned for reuse.
    The reality is that current Medicare payment reform has overcorrected the intent of Congressional law in 2003 by more than three times, and has left not only drug reimbursement at levels that do not cover the costs of purchasing and acquiring the drugs in the physician office, but additionally fails to cover the costs of essential services such a pharmacy handling, physician treatment and care management, and extensive amounts of nurse time in coaching and counseling patients, in addition to treatments and chemotherapy administration. Already, across the country, physician offices are closing, and access to cancer care for Medicare patients has been dramatically disrupted.
    Now, in the year 2006…we are starting to win the war on cancer, and oncology offices resemble acute care departments more than a “traditional” physician’s office. Chemotherapy treatments have become ever more complex, and each new drug that occurs is often approved by the FDA for use as an enhancement to older therapies, rather than a replacement. Few oral cancer drugs are given in a vacuum, as replacements for traditional injectable treatments – because they are in fact NOT replacements and cannot then be considered as alternatives to traditional therapies, but as adjuncts. In addition, the complexity of treatment is no less complex for orals, and the need for close monitoring in the physician office is no less urgent.
    So, Mr. Pawelski makes several points that do not bear up under the scrutiny of reality.
    There is no “oncology prescribing franchise”. There are, however, very costly new treatments that have been approved as efficacious by the FDA over the last decade that do, in fact, cost the healthcare system (including physicians) much more than older, more primitive treatments. An antiquated payment system built by the government (NOT the oncologists) unfairly underpaid oncologists for the costs of providing care and instead, took the easy way out by building a margin on drug reimbursement to cover those costs. That system no longer works, but it is not an indicator of oncology prescribing misconduct.
    Oral cancer treatments are not a panacea for replacing injectable therapies. In fact, the toxicities and potential side effects and complications from oral treatments are just as serious as those of injectables, and oral treatments are usually an adjunct to traditional therapies, NOT a replacement. Unfortunately, we do not yet live in the world of the Jetsons, and there is no magic pill that can cure cancer and eliminate oversight and care management by the treating physician.
    Mr. Pawlski referred to the NBC NIghtly News stories with undeserved praise. NBC NIghtly News has aired two stories on oncology recently, both of which were grossly biased and misleading, and neither presented the true story of community oncology. The first story purported to present oncologists as unfairly obtaining their incomes from drug prescribing (which I have already debunked above). The second looked at a demonstration project introduced by Medicare in 2005 and vilified oncologists for participating. There were indeed many flawed reasons for CMS creating this study, not the least of which was that they were collecting data and in turn created a way to replace for oncologists some of the overzealous cuts in reimbursement that CMS itself had made for cancer care. But, there was a silver lining to the study. NBC and the OIG conveniently ignored the only study conducted on the clinical aspects of the project, by Linda Elting of MD Anderson Cancer Center. The comprehensive study completely invalidates the NBC report and the unsubstantiated hyperbole stated by the NBC reporter who declared, “But oncologists told investigators they didn’t believe it would lead to better care.” The project did lead to better care, better outcomes, and fewer adverse events.
    Also, NBC conveniently ignored the whole process set in motion by MMA that intended to modernize Medicare payments for cancer care by reducing payments for drugs but increase payments for essential services. There was no mention that Congressional intent under MMA was to create $4.2 billion in savings over ten years, yet the only valid report on the real impact – The PricewaterhouseCoopers report shows $13.7 billion in reductions over 10 years.
    Clearly, CMS appropriately responded to make a transitional payment on the road to permanent solutions (that still, unfortunately, have not materialized). CMS intelligently tied this payment to quality that was also ultimately linked to outcomes. This payment also offset the irrational 22% reduction in chemotherapy administration that occurred one year after MMA while drug reimbursement dropped an additional 24.7% (on top of the 10.5% reduction in drug reimbursement that occurred the first year of MMA). This transitional demo project focused on quality, the importance of nursing care and assessment, and reducing severe and costly adverse events. It could be safely argued that the project saved taxpayers money as a large number of costly events resulting in hospital admissions were avoided.
    To this day, The Community Oncology Alliance (www.communityoncology.org)agrees with the 2005 demonstration project and regrets that CMS did not steer this to a permanent set of codes to validate the role of nurses in symptom assessment, management, and intervention. As an aside, when the demo project was created we advised CMS and Congress to waive the patient co-pay.
    There are some wonderful oncologists working with the public and private payers to reform, not just the payment system, but also to define and refine the knowledge base upon which we made treatment choices. This movement toward evidence-based medicine and comprehensive treatment protocols is groundbreaking and will take some time. In the meantime, please know that attitudes like those of Mr. Pawelski may make good soundbites, but you and your loved ones are actually able to receive quality cancer care from those who make up community oncology under a far different reality, and we indeed are a lucky nation to have this level of care.
    The fact is, that even as the Institute of Medicine identified as much as 50% of all healthcare as being inappropriate or “waste”, the delivery of cancer care according to well established and widely utilized care guidelines is more than 80%. We are working on improving that to closer to 100%, but in the meantime, we should not vilify those who care so well for cancer patients on a daily basis. It is easy, but shameful, to blame those who work long, hard hours caring for cancer patients. The oncologists, nurses, clinic staff, and administrators took the system provided for them and have created the world’s best cancer care delivery system. For the past four years, CMS has changed the coding for cancer care annually – without logic or a reasonable end point in mind. The onus of a flawed system remains in the hands of Congress and CMS to resolve.

  6. The closer that people look at what we are saying, the more they will understand that what we are saying is true.
    The closer that people look at what ASCO has been doing, the more they will be unsettled, if not downright apalled.

  7. Besides bacterial culture and sensitivity testing and cell culture assay tests, there is also estrogen receptor, progesterone receptor, Her2/neu, immunohistochemical staining for tumor classification, OncotypeDX, EGFR amplification/mutation, CT, MRI, Pet Scans to measure tumor response to treatment, that have been validated for predictive accuracy. There is no evidence to the contrary, no evidence that these arn’t beneficial, and no evidence that there isn’t any benefit of assay-directed therapy over standard treatment protocol.
    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.” These are diagnostic tests and should be held to that criteria, and not to that of therapy.
    The mantra continues…..

  8. The mantra continues:
    “Why are they afraid to honestly evaluate and report the “accuracy” of cell culture assay tests?”
    Afraid? Ad hominems flow freely.
    With absolutely no evidence at all that cell assays are of any benefit we still have one blogger on this planet that will continue his assault on medical science. Fortunately, science continues to win over speculation.
    Diagnostic accuracy does not necessarily result in improved management outcome for patients, yet he wants us all to pay for his tests. He ill equate this bacterial C&S tests and their approval. A bad analogy, again. He needs to refresh his memory about the development of these tests.
    In addition to aiding in discovering new pathogens, C&S techniques also contributed to studies of the epidemiology, pathophysiology, and treatment response of the newly recognized diseases, providing further evidence for causal relationships between disease and organism. Culture provided the basis of other supplemental tools to elucidate the causes of microbial disease and to study the clinical and biological features of emerging bacterial diseases. These tools are not only antigenic and serologic assays but also in vitro and in vivo disease models for pathophysiologic studies and antimicrobial susceptibility testing, plus extensive genetic sequencing. The isolation of emerging pathogens serves, therefore, not only as a means for diagnosis but also as a route to enhance understanding of the diversity and epidemiology of emerging bacteria and the infections they cause.
    He equates the approval of this with unproven cell culture assays.
    Dr. Fleming is rolling over in his grave.

  9. As you can see, Michelle is well aware that ASCO itself, will no longer go unchallenged. Why are they afraid to honestly evaluate and report the “accuracy” of cell culture assay tests? The tests have been proven “accurate.” And there are obviously lots of situations where a rational oncologist and patient would conclude that the evidence from an “accurate” test would be of help to guide treatment for cancer patients.
    No other lab test in history has anything other than evidence of “accuracy” to either commend it or condemn it. But ASCO won’t even look at the “accuracy.” They are misguided in not recognizing that they are trying to mate notoriously heterogeneous diseases into one-size-fits-all cliinical trial treatments. They devote 100% of their clinical trial resources into trying to identify the best treatment for the average patient, in the face of evidence that this approach is non-productive. However, such unsuccessful experiments will never be viewed as such by the thousands of people whose careers are supported by these experiments. But with institutions making a living predominately from clinical trials, no wonder ASCO has not supported the use of cell culture assays outside the clinical trial. Don’t want to disturb the income flow.
    And 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.

  10. Jason, where did I say doctors are “worthless”? But they can increase their worth by not always thinking healthcare is all about them. I don’t choose doctors services like I choose a hot dog, I need doctors sevices like I need oil companies to buy gas from, (another monopoly) but the goals and issues of oil companies are not mine or are they in the long term interests of the nation and the problems we face. If doctors acted more as patient advocates then I think the public would overwhelmingly get behind them. But getting the AMA (doctors union) out of its morass is not possible under present conditions.

  11. “Docs (in general) are not part of the solution, they are an impediment to solutions in healthcare.”
    Uhh… if doctors are worthless then why in god’s name do you choose to use their services? By all means go to your neighbor down the street and see if he can propose a remedy for your symptoms.

  12. Docs (in general) are not part of the solution, they are an impediment to solutions in healthcare.

  13. The NBC Nightly News Story was right-on. The situation does beg the ethical question: are they over prescribing? Doctors in other specialties simply write prescriptions. But oncologists make most of their income by buying drugs wholesale and selling them to patients.
    Steve Coplon, COA’s Executive Director, states “Cancer drugs are not like other prescription medications. They must be administered, typically intravenously over long periods of time, under the supervision of trained medical professionals. However, most or all cancer drugs do not have to be administered.
    A National Coalition for Cancer Survivorship (NCCS) poll found that 89% of Americans said that the distinction between oral and intravenous applications should be abolished so that Medicare beneficiaries can have access to the best drugs to treat their form of cancer.
    Apparently, Medicare has gone far in accomplishing that task. Nearly all generic cancer drugs and 70% of brand-name cancer drugs are covered by the Part D plans. Most of the brand-name drugs not covered had generic equivalents that are covered. And a number of trusted, old (generic) agents have been found to be just as effacious as the more expensive brand name ones.
    Many infusional therapies are typically biotechnology drugs made of complicated proteins that are injected. This makes them several times more expensive than traditional pill-form pharmaceuticals.
    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. 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. It requires individualized treatment based on testing the individual properties of each patient’s cancer.
    Cancers that can be treated with oral chemotherapy include, breast cancer, colon and colorectal cancer, Leukemia, chronic myeloid leukemia, chronic lymphocytic leukemia, acute promyelocytic leukemia, acute non-lymphocytic leukemia, Lymphoma, cutaneous T-cell lymphoma, small cell lung cancer, non-small cell lung cancer, Kaposi’s sarcoma, prostate cancer, multiple myeloma, ovarian cancer, brain tumours.
    Oral chemotherapeutic agents are easy to use and offer the promise of less frequent visits to office-based or hospital 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.
    For the rest of the story, Google: “Drug Selection in Cancer Treatment” or “Drug Selection in Breast Cancer Treatment”

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