How Oncologists
Choose Between Otherwise
Equally Acceptable Treatment Regimens
New! March 8, 2006. Joint
Michigan/Harvard study confirms medical oncologists choose cancer
chemotherapy
based on reimbursement to the medical oncologist.
Introduction:
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:
http://www.nytimes.com/2006/03/08/health/08docs.html
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.