How Oncologists Choose Between Otherwise
Equally Acceptable Treatment Regimens

March 8, 2006.
Joint Michigan/Harvard study confirms medical oncologists choose cancer chemotherapy based on reimbursement to the medical oncologist.


In November of 1999, I called attention to the fact that medical oncologists in private practice were deriving most of their income by running a retail pharmacy concession, in testimony I gave to the Medicare Executive Committee. 

Just published in the journal Health Affairs is a joint Harvard/Michigan study entitled "Does reimbursement influence chemotherapy treatment for cancer patients?" In a study of 9,357 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 (Jacobson, M.,O'Malley, A.J., Earle, C.C., et al. Health Affairs 25(2):437-443, 2006).  The following is a link to the March 8, 2006 New York Times article describing the study:

One of the more interesting aspects of this story is the following:

[Quoted from the above New York Times article]:

"An executive with the American Society of Clinical Oncology, Dr. Joseph S. Bailes, disputed the study's findings, saying that cancer doctors select treatments only on the basis of clinical evidence. 'All of us are looking at clinical trials,' he said."

So ASCO's Dr. Bailes maintains that drugs are chosen only on the basis of "clinical evidence."  Well, here's what's peculiar: 

Neil Love, MD reported a survey of (1) breast cancer oncologists based in academic medical centers and (2) community based, private practice medical oncologists.  The former oncologists do not derive personal profit from the administration of infusion (i.v.) chemotherapy, the latter oncologists do derive personal profit from infusion (i.v.) 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 prescribed an oral dose drug (capecitabine), while only 13% perscribed infusion (i.v.) 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 (i.v.) drugs, and 29% prescribed the expensive, highly remunerative drug docetaxel (click here to see a graph of these data, and click here for a link to the full text of the study [see figure 37, volume 2, issue 1, 2005]).  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.