Reimbursements Sway Oncologists' Drug Selection
by Gregory D. Pawelski
The shift, almost 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 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.
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 (Taxotere).
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.
In addition, 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.
So we have 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
http://patternsofcare.com/2005/1/images/Picture-37a.gif
Gregory D. Pawelski
Pennsylvania
USA
2 comments:
The situation is even more complex. See Health Care Renewal:
http://hcrenewal.blogspot.com/2006/03/complexity-conflicts-of-interest-and.html
Report: Doctors' $275M Study Questioned
By KEVIN FREKING
The Associated Press
Tuesday, August 29, 2006
http://www.topix.net/content/ap/3252578919265568528409953178163644686735
In 2005, CMS initiated a one-year demonstration project for cancer patients undergoing chemotherapy. The demonstration focused on measuring patient outcomes in three areas of concern often cited by patients undergoing infusional chemotherapy: controlling pain; minimizing nausea and vomiting; and reducing fatigue. Oncology Practices reporting data on all three factors qualified for an additional payment of $130 per encounter for chemotherapy administration (a financial incentive to use infusional drugs over oral drugs). That included a $26 patient copay.
A Republican, Senate Finance Committee Chairman Chuck Grassley, found out from the Health and Human Services' inspector general's office that the value of the approximately $300 million-a-year demonstration project to report this information was for nothing. Providers were being paid $130 to simply forward the data that was already collected.
CMS had decided to continue the demonstration project for 2006, with additional reporting to take a further step toward encouraging quality care and promoting so-called evidence-based best practices that have been proven to lead to improved patient outcomes. According to CMS, the payment for this oncology demonstration project is $23 per encounter. The new 2006 demonstration project's objective is to have oncology payments increasingly focused on patient-centered care, rather than chemotherapy administration.
While a Michigan/Harvard study (before Medicare reforms) documented a clear association between reimbursement to oncologists for the chemotherapy and the regimens which oncologists select for their cancer patients, a "Pattens of Care" study (after Medicare reforms) showed results that Medicare reforms are still not working. It is still an impossible conflict of interest. Once a decision to give chemotherapy is taken, oncologists receiving more-generous Medicare reimbursements used more-costly treatment regimens. (Google: "Drug Selection in Breast Cancer Treatment")
According to findings in the American Medical Group Association's 2005 Medical Group Compensation & Financial Survey, most specialties saw modest increases in compensation in 2004. The majority of specialties experienced increases at or just above the rate of inflation, and the primary care specialties saw increases of 6% - 8.8%.
The survey found that during 2004 three specialties experienced the largest increases in compensation: general surgery (8.89%), pediatrics & adolescent (8.76%), and hematology & oncology ($8.52%). In addition to pediatrics and adolescent, other primary care specialties saw increases: family medicine (6.31%) and internal medicine (7.57%).
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