Wednesday, April 19, 2006
Oncologists Profit On Chemotherapy Drugs They Prescribe To Cancer Patients
Cancer Chemotherapy ConcessionThe April edition of CancerWire focuses on the Chemotherapy Concession which allows oncologists to make a profit on the chemotherapy drugs that they prescribe to cancer patients.
(PRWEB) April 19, 2006 -- A recent study published in the journal Health Affairs Does Reimbursement Influence Chemotherapy Treatment for Cancer Patients revealed that the so-called Chemotherapy Concession is still in effect and that financial reimbursement has a direct effect on which chemotherapy drugs are prescribed to patients.
This study by researchers from the University of Michigan and Harvard University found that oncologists who were more generously reimbursed prescribed more costly chemotherapy regimens to metastatic breast, colorectal, and lung cancer patients. The study demonstrated that the chemotherapy concession (doctors making profits from prescribing chemotherapy) that brought Congressional attention several years ago is still with us and is still controlling prescribing patterns.
The Chemotherapy Concession
Unlike other doctors, medical oncologists (doctors who prescribe chemotherapy) can profit directly from prescribing certain drugs. Oncologists can purchase chemotherapy at lower prices than the amounts that the insurance company pays them and then pocket the difference. This mark-up, which can be as high as 86%, is called the chemotherapy concession. The Health Affairs study revealed that this type of reimbursement prompts some oncologists to use more expensive drugs with better mark-ups for the doctor. For example, the study found that for breast cancer patients, a one-dollar increase in a physicians reimbursement resulted in the use of chemo drugs that cost $23 more. The authors said, "Although reimbursement seems to have little effect on the primary decision to administer palliative chemotherapy to patients with advanced solid tumors, it appears to affect the choice of drugs used."
Why This Hurts Patients
The Chemotherapy Concession can harm patients in at least three different ways: 1) it creates a potential conflict of interest; 2) it may expose patients to more experimental drugs; 3) it may deplete a patients insurance benefits (i.e. drug coverage).
Potential Conflict of Interest - The Chemotherapy Concession gives oncologist other reasons to prescribe chemotherapy and select specific drugs. Patients must now ask why their doctor is prescribing more and different chemo. What is behind the decision? Oncologists insist that money has nothing to do with it. But, a New York Times article about the University of Michigan/Harvard Study (Study links cancer doctors pay and their treatment) cites Dr. Craig Earle, one of the study's authors and an associate professor of medicine at Harvard and an oncologist at the Dana- Farber Cancer Institute in Boston. According to the Times, Dr. Earle stated that despite their insistence that oncologists treatment decisions are based solely on what is best for the patient, these decisions are affected by payment policies and other financial influences, including gifts from drug companies.
Newer Experimental Therapies - Typically more costly chemotherapy drugs with higher reimbursement are those that are newer. Because the newer drugs have less of a track record in terms of safety and efficacy (i.e. less post approval marketing surveillance), there may be less known about their safety and efficacy. Therefore, it is possible that a patient may get a drug that is more dangerous to them or less efficacious because of a monetary incentive.
Patients Insurance - Someone is paying to put that extra money in the oncologists pockets. Because the costs of premiums are directly related to expenditures, the chemotherapy concession hurts all of us by siphoning money away from patients, employers and payers and into the hands of one class of provider.
What You Can Do
Obviously, a patient wants a clinical decision to be based only on clinical information, not on how much money the doctor gets to keep. If you are a patient, you should know if there are any financial incentives at work in determining what cancer drugs you are being prescribed. Ask your oncologist: Why are you prescribing these drugs? What is their published efficacy and toxicity in other patients with the same cancer? Do you have any research or financial interests in prescribing these drugs? Are these drugs a profit center for you in respect to reimbursement?
Obviously you do not want a confrontational relationship with your doctor. And just because a doctor makes a profit from the drugs they prescribe does not mean that the drugs are inappropriate for you. A trusting partnership between doctor and patient that facilitates informed consent is the goal for many proactive patients. Such a partnership, however, may require an understanding of all the factors that lead to a treatment recommendation.
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Of course, none of this information in CancerWire is a substitute for professional medical advice, examination, diagnosis or treatment and you should always seek the advice of your physician or other qualified health professional before starting any new treatment or making any changes to an existing treatment. No information contained in Cancer Monthly or CancerWire including the information above, should be used to diagnose, treat cure or prevent any disease without the supervision of a medical doctor.
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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.
There was a joint Michigan/Harvard study authored by Drs. Joseph Newhouse and Craig C. Earle, entitled "Does reimbursement influence chemotherapy treatment for cancer patients?" It 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 tended to base their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist.
The study adds to the 'smoking gun' survey by Dr. Neil Love, entitled "Patterns of Care." 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.
And 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.
Two scientific studies giving us a dose of reality that once a decision to give chemotherapy is taken, oncologists receiving more-generous Medicare reimbursements used more-costly treatment regimens.
Sources:
http://content.healthaffairs.org/cgi/content/abstract/25/2/437
http://patternsofcare.com/2005/1/editor.htm (figure 37, volume 2, issue 1, 2005)
Superficially, it sounds like a great expose, greedy clinics/doctors trying to make money by pushing drugs. The New York Times article states that the drugs, given by injection, have been heavily advertised, and there is evidence that they have been overused, in part because oncologists can make money by using more of the drug. That's not really a new revelation. We've been down that road before without much done to change it.
According to Dr. John Glaspy, director of UCLA's Outpatient Oncology Clinic, one complicating factor, experts say, is that oncologists make significant revenue buying cancer drugs from manufacturers and charging patients a higher price for receiving the drugs in their offices. That profit motive could influence some doctors' decisions. However, patients with anemia, which can cause sluggishness in its early stages and can be fatal in advanced phases, can get blood transfusions, typically every few weeks, instead of using EPO.
Could it be that increased numbers of red cells deliver more oxygen to the tumor cells and thereby increase their activity across the board, including with respect to invasion, proliferation, and metastasis? On one hand they're developing drugs to halt and reverse angiogenesis while on the other hand they're helping the tumor to obtain more oxygen with existing vasculature. And nobody in charge foresaw that? Amazing how they can apply differing standards for proof or benefit when profit is involved.
http://query.nytimes.com/gst/fullpage.html?sec=health&res=9C06EEDB1331F933A25750C0A9619C8B63
In panel discussion that highlighted the 12th annual conference of the National Comprehensive Cancer Network, Lee Newcomer, former chief medical officer and currently an executive with Minneapolis-based United Health Group, pointed out that in reviewing records of patients who were prescribed the drug erythropoietin -- an expensive agent that boosts blood supply in patients with anemia -- said that 44 percent of those patients had blood work-ups that would indicate they were not anemic.
http://www.sciencedaily.com/upi/index.php?feed=Science&article=UPI-1-20070316-20215500-bc-us-cancercosts-analysis.xml
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