Physicians

PHYSICIANS/POLICY: NY Times is surprised about its Ps and Qs in Prostate Cancer Therapy

Das KapitalSo there are three treatments for prostate cancer. Medicare pays physicians a whole lot more for one (new snazzy non-invasive one that patients prefer too)  than the other two. So they rush off to get the necessary equipment and staff-up to perform the new procedure. Then they start doing that rather more than they others. And the NY Times is surprised!

Wow. Just wait till they hear about chemotherapy, and how much of that treatment “choice” is based on incentives to physicians. (Cue Greg to tell us!)

Just another reminder why non-globally budgeted FFS in a system with no mandated technology cost-effectiveness assessment does not work. And that’s roughly what Medicare provides. Instead we should be trying to figure out what is the best patient long-term outcome is for a pre-determined amount of spending.

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  1. Why is it shocking to everyone that when there is an opportunity to legally increase monetary income, smart people find a way to do it, full speed ahead.
    ASTRO knows that urologists were furious about losing turf to radiation, but seeds became the middle ground. Then when hospitals began screwing doctors left and right, docs realized if they banded together, they could take over profitable outpatient based care.
    Now, the urologists ironically are going to hose over radoncs, but in truth, they cannot do it without radoncs who work with them. Those who go with uro-rad may or may not do well – after all, who wants to nothing but urology cases? How will a good rad onc keep up their chops? And when the urologists dump you? Then good luck with your CV… ‘Yes, all I did for the last 3 years was IMRT prostate…’
    Gee doc, where’d ya work at again?

  2. I agree that patient choice plays a large role in the ultimate treatment decision. However, as a Rad Onc I have seen first hand hoe this works. When I started in practice the only referals I received from urologists were patients too risky for radical surgery. The urologists then set up an outpatient center in which they could collect the technical component from a seed implant and all of the sudden the patients that were refered to me “wanted” a seed implant. They were told how much better that was than IMRT by the urologists. Now that they have figured out that they can own a linear accelerator and collect the technical fees for that all of the sudden their patients “want” IMRT. Studies have shown IMRT and seed implants to be comparable as far as outcome. The bottom line is that what the patients “want” is greatly influenced by the presentation and bias of the urologists. There bias is clearly to the procedure with the greatest monetary profit for them.

  3. Actually it has been a republican controlled Congress for longer than 6 years. I am sure they will try to do quite a bit of accommodating and the first order of business will be to raise taxes on all those rich people making over $75k per year. We will see.

  4. After the last six years, perhaps the new Congress will finally try to accommodate?

  5. “Could it be that a certain negative bias is directed at the NYT because of its critical articles about the Bush Administration and their war in Iraq? Which by the way are proving correct.”
    I read the NYT eventhough it has a leftward tilt. I don’t believe I have bashed it here.
    “The ideal would be if patients received their treatment modality at some treatment center which wasn’t involved in the decision to treat or not to treat and in which the physician didn’t have a financial interest.”
    That was tried in the past but the laws were relaxed. It was too restrictive and led to patient access issues.

  6. 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 their treatment modality at some treatment center which wasn’t involved in the decision to treat or not to treat and in which the physician didn’t have a financial interest.

  7. Well pgbMD I actually went to and read your link to the article in Oncology Times. Be careful what you wish for. It shows that the New York Times Article got it right. In fact the NYT was quite a wimp at reporting this issue compared to the Oncology Times Article. Could it be that a certain negative bias is directed at the NYT because of its critical articles about the Bush Administration and their war in Iraq? Which by the way are proving correct.
    I’ve taken a few pieces out of the OC Times article that bring out the same issues and more as the NYT.
    Start quote:
    “…tactic that may ironically mean that more men are being steered to radiation therapy by their urologists
    for financial rather than medical reasons?”
    “What initially appeared to be a routine information-gathering assignment soon expanded into more and more of a mystery as numerous experts involved in prostate cancer research and treatment, as well as professional society representatives, and those from the business side of medicine, declined to comment despite many saying that the issue was an important one worth covering.”
    “Renowned prostate cancer experts at some of the nation’s leading cancer centers said they didn’t want themselves or their institutions involved or mentioned in this story, some saying that it was not their issue, others, that it was too controversial.
    A spokesperson for the American Society for Therapeutic Radiology and Oncology first agreed that this was an
    important topic, and then said that the Society would neither comment nor issue what had been a promised statement by its CEO Laura Thevenot, noting “ASTRO can’t get involved with this due to antitrust issues.”
    The President and CEO of WellMed, a practice-management company that contracts with specialty medical
    practices in San Antonio, refused to be interviewed; his office said it was an oncology issue, and wouldn’t respond to OT’s question about whether it was really more about reimbursement.”
    “However, J. Brantley Thrasher, MD, a spokesperson for the American Urological Association, who developed
    the recent AUA guidelines for the diagnosis and treatment of prostate cancer with Ian Thompson, MD, said during a telephone interview that there was no
    question that cutbacks in reimbursement in all medical practices had continued to create downward pressure to
    create new revenue streams.”
    “A four-year clinical trial evaluating both modalities is under way in the United Kingdom, but could probably
    never be done in the United States with its current health care system, according to experts.”
    “Dr. Thrasher agreed. “Many men look for information on the Internet and elsewhere, and they still come in
    and ask, ‘Doc, what do you think? I’m still confused.’
    “This is exactly the problem. They come to us for guidance, and with the absence of definitive data, there is the potential that guidance can be offered
    on behalf of economic rather than medical factors. There’s been a lot of talk in this field about conflict of interest.”
    “The Urorad business model circumvents the legal technicalities of the anti-kickback provisions since the
    IMRT facility is owned by the urology practice and, in most cases, the radiation oncologist is an employee.”
    “Dr. Prestidge had expressed concern to OT that Urorad’s
    delivery of IMRT services might be suboptimal, and claimed that it wasn’t possible to do a good job
    pushing 50 to 60 patients a day through IMRT.”
    “He also said he had spoken with members of ASTRO’s regulatory committee who said that what Urorad was
    doing was not illegal, “although it was
    possibly unethical.” It was Dr. Prestidge who prompted this article.”
    “Mack Roach 3d, MD, Professor of Radiation Oncology and Urology, Director of Clinical Research for the
    Department of Radiation Oncology, and Interim Chair of Radiation Oncology at the University of California,
    San Francisco Comprehensive Cancer Center, told OT that he had received a copy of a Urorad marketing e-mail
    about a year ago from a colleague who was sharing the information with other academic-based radiation oncologists. “When I first saw it, I thought it
    was a bad joke,” he said. “And when I realized it was real I felt very uncomfortable with it. My biggest concern was the flavor of the e-mail since it seemed to push advancing a major financial incentive as a fundamental reason for patient care.”
    “Stephen M. Hahn, MD: “If medical decisions are being made for financial reasons and what’s being recommended is not necessarily best for the patient, then there’s a
    problem regardless of what the Stark Law says.”
    It is also crucial that both urologists and radiation oncologists make independent medical evaluations rather
    than having a patient seen just by one and referred to the other for treatment,which could give the appearance of a conflict of interest, if not constitute an
    actual one.”
    End quote.
    So it does appear it IS all about money, and ideology, when bashing the NYT.

  8. Once again the New York Times gets the story completely wrong. The total bill for prostate surgery is over $80,000 when the cost of dealing with the horrendous side effects of surgery is taken into account.
    Prostate surgery is one of the most difficult procedures there is to perform. The prostate is buried deep within the body so the surgeon has to perform the surgery by feel. It does not help that the whole area is flooded with blood. It is not surprising that incontinence and impotence are common side effects of the surgery. The best surgeons have a 90% cure rate. The worst ones have a 68% cure rate.
    Radiation delivery machines introduced in the past 4 years have a cure rate in the high 90s if the cancer is caught in time. There are minor side effects during treatment, and lasting side effects are rare.
    So radiation has a higher cure rate, at a lower cost, with far fewer side effects. If a urologist cares about his patients, he would be switching to radiation treatments. And if a person wants the truth, don’t read the New York Times.

  9. In regards to the NYT article and prostate cancer in general, prostate cancer is a black hole. The problem is PSA testing. Prostate cancer is common. Wouldn’t surprise me one bit to learn I have a few prostate cancer cells lurking within. Would I get a radical prostatectomy were this diagnosed? No. Would I get radiotherapy? Probably not. PSA testing is a bonanza for urologists. Lots more prostate cancer gets diagnosed. They get to do lots more I.M.R.T.’s. Would these people have died of prostate cancer without the procedure? I doubt it.

  10. “I don’t think Dr. Glatstein’s comment was self serving.”
    Of course his comment was self serving. This is a good old fashioned urology/radiation oncology turf battle and the urologists will win because they own the patients. Don’t be fooled, I am sure Dr Glatstein is quietly purchasing an IMRT at this very moment.
    “take the financial incentive out of decisions and you have a good chance of a better decision.”
    To the contrary, investment in technology and competition in medicine leads to more choices, less invasive treatment options, more rapid deployment of newer technology, and ultimately a more informed treatment decision and a happy patient.

  11. pgbMD, I don’t think Dr. Glatstein’s comment was self serving. He can certainly buy the latest and greatest new Tech and cash in himself. I think his point of docs having a vested interest in performing certain procedures is key here. As in politics, take the financial incentive out of decisions and you have a good chance of a better decision. Should docs have to devulge their financial interest as stock brokers do? As to those “informed prostate cancer patients”, I think they have information not education. If they presented themslves in your office demanding you sacrifice a chicken to cure their prostate cancer, would you just do it, claiming “patient demand”? Should they be also allowed to use a local so they can back seat drive the operation? Personal responsibility is not only on the pull side, it’s also on the push.

  12. Dear JD:
    The Commonwealth Fund study addressed efficiency in terms of per-capita payments, not in terms of administrative overhead. While I agree that Medicare has lower administrative overhead than private plans, the crucial policy question is whether the sum of administrative overhead + provider payments is greater in public programs or private programs. I don’t have enough space here to effectively discuss that issue, but I do urge you to look up a Health Affairs article written by James C. Robinson about 8 to 10 years ago, in which he debunks some of the more simplistic notions that proponents of public programs have about administrative overhead in private health plans. If you can’t find the citation, let me know and I will be happy to send it to you.
    Eric

  13. Just to clarify, my previous post on was not an argument in favor of defined contribution health plans or any other mechanism for shifting more financial risk to patients. What bothers me about the recently released Commonwealth Fund study is that the authors conclude the Medicare’s administered fee-for-service (FFS) pricing system is superior (in terms of “efficiency”) than Medicare’s HMO pricing system, yet they refuse to acknowledge the perverse impacts on quality of care which can result from the Medicare FFS system. Medicare’s reimbursement policies for oncology care are among the most egregious in the health insurance industry—while I am well aware of the potential pitfalls associated with capitation (e.g., withholding of necessary care), I am hard pressed to think of any payment policies which are more harmful to patients some of the policies inherent in Medicare’s FFS program.
    Eric

  14. Eric,
    You missed the point. Claims about the superior efficiency of Medicare over private commercial insurance don’t have anything to do with the fee schedule. “Efficiency” refers to administration, and it is here that Medicare has an advantage over private plans. Medicare pays almost nothing for sales and marketing, pays no stock options to CEOs, operates on a vast scale, does no underwriting, etc.
    Medicare Advantage plans will always be more expensive administratively than traditional Medicare, and small private insurers who spend 25% of SG&A on commisions and marketing will likewise be at a disadvantage to a government system like the VA system which not only has no commissions, but doesn’t need to deal with myriad hospital and physician systems.
    All that can be true at the same time that unbudgeted FFS is a disaster from a public interest perspective.
    Two final points:
    1. Medicare is often compared to non-medicare commercial insurance. This is slightly unfair because PMPM medical costs are so much higher for Medicare that it lowers the administrative expense ratio. Instead, Medicare should be compared only with Medicare Advantage plans on admin costs.
    2. The VA system is an integrated delivery system which has economies that the fragmented insurer/provider interface structurally lacks. It would be fairer to compare the VA with Kaiser or similar organizations when judging whether private plans can achieve the efficiencies of public ones. I think Kaiser’s AER is extremely low, something like 3-6%, which is in the same range as public systems like the VA. Someone correct me if I’m wrong.

  15. “trying to figure out what is the best patient long-term outcome is for a pre-determined amount of spending.”
    Long term is the key here. You want long term comparisons between two known effective treatments. That takes a long time. Give the patient a choice of effective treatments until those long term comparisons see the light of day.
    That doesn’t mean we should reimburse for, as yet, the completely unproven individualized chemotherapy treatment as Greg would have everyone believe is the silver bullet. I know he would say I am talking out of both sides of my mouth with my endorsement of I.M.R.T, but it’s obviously apples and oranges. One works the other is without proof.
    And, finally as for chemotherapy reimbursement:
    http://waysandmeans.house.gov/hearings.asp?formmode=view&id=5247

  16. “Dr. Eli Glatstein, a professor of radiation oncology at the University of Pennsylvania, said he was concerned that some urologists would steer patients to the new treatment because they owned the technology and could greatly profit from its use.”
    You have to be careful here, this comment is being made by a rad onc whose turf is being trod on by urologists. I guess the rad onc would prefer urologists steer the patients towards his seeds that require general or spinal anesthesia and a same-day hospital admission. Sorry folks but this is being patient driven. You would be amazed how informed prostate cancer patients are, especially in the NY/Long Island area. They usually come into the urologists office telling the doctor what treatment they want and will seek out those with the newest least invasive technology. Of course, all you skeptics will just line up for the orchiectomy, because it is the right thing to do and will save lots of money for the greater good.

  17. “It’s all money-driven, and it’s a shame medicine has come down to this,” said Dr. Brian Moran, a radiation oncologist in Chicago, who specializes in radioactive-seed implants, in which tiny radioactive pellets are placed into the prostate. His clinic is paid $15,000 or less for the procedure, with the urologist on the case getting about $900.”
    “Dr. Eli Glatstein, a professor of radiation oncology at the University of Pennsylvania, said he was concerned that some urologists would steer patients to the new treatment because they owned the technology and could greatly profit from its use.”
    So Eric, where does this fit with your “personal responsibility” solution to healthcare costs?

  18. I could not agree more, Medicare’s reimbursement policies for oncology care are biased in favor of chemotherapy, which is both a financial and moral scandal. So why, Mr. Holt, do you always drink the Kool-Aid whenever an outfit like the Commonwealth Fund publishes a study (as it did last week) promoting the “virtues” of Medicare’s relatively “efficient” payment system vs. private payers like HMOs? You can’t have it both ways.

  19. “Instead we should be trying to figure out what is the best patient long-term outcome is for a pre-determined amount of spending.”
    I guess then you are advocating bilateral orchiectomy for everyone with prostate cancer? It certainly would be the cheapest form of therapy and is quite effective. I am sure you will be the first in line…

  20. Mr. Staiano, 75, was one of several patients treated by I.M.R.T. in Plainview, N.Y., who said they suffered only minor side effects after the nine-week course of radiation.
    “This treatment is fabulous,” said Mr. Staiano, a retired tape editor for NBC, who said that his side effects were minimal. “If I ever get cancer again,” he said, “this is the way I want to go.”
    This overall is the drive by Medicare and the insurers to push what was typically hospital based treatments (ie radical prostatectomy) outside the hospital to save money. Eventhough radical prostatectomy reimburses the surgeon <$2000, the overall hospital charges are closer to $25000 for the whole package. Granted, $40000 is more than $25000, but as the technology becomes cheaper this cost will drop off pretty quickly. There is a new outpatient prostate cancer therapy coming that uses high intensity focused ultrasound transrectally (so no incisions) and this can be done in the office (and will be much cheaper than the IMRT). In my book, anything that can be done in the office saves money over the hospital. Medicare and the insurers know this as well.

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