Healthy Skepticism International News
Selling cancer chemotherapy with concessions creates conflicts of interest for oncologists
by Gregory D. Pawelski
I became intensely interested in ovarian cancer by virtue of working through, enduring and surviving my wife’s illness. I’ve gotten a street education by virtue of voluminous reading and hundreds of hours of past and ongoing personal communication with noted authorities in the field.
The shift in the United States, more than 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.
This was first brought to attention at a Medicare Coverage Advisory Committee meeting in 1999, in Baltimore, Maryland. There was a gastroenterologist in attendance who complained that Medicare had cut his reimbursement for colonoscopies from $400 to $108 and how all the doctors in his large, multi-specialty internal medicine group were hurting, save for two medical oncologists, whom he said were making a killing running their in-office retail pharmacies .
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 administered them intravenously to patients in their offices.
Not only do the medical oncologists have complete logistical, administrative, marketing and financial control of the process, they also control the knowledge of the process. The result is that the medical 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.
A joint Michigan/Harvard study entitled, “Does reimbursement influence chemotherapy treatment for cancer patients,”  confirmed that before the new Medicare reform, medical oncologists are more likely to choose cancer drugs that earn them more money. A survey by Dr. Neil Love, published in “Patterns of Care,” showed results that the Medicare reforms have not solved the problem of variations in oncology practice.
A patient wants a physician’s decision to be based on experience, clinical information, new basic science insights and the like, not on how much money the doctor gets to keep. A patient should know if there are any financial incentives at work in determining what cancer drugs are being prescribed.
It’s not that all medical oncologists are bad people. It’s just that the system is rotten and still an impossible conflict of interest. Some oncologists prescribe chemotherapy drugs with equal efficacies and toxicities. I would imagine that some are influenced by the whole state of affairs, possibly without even entirely admitting it. Social science research shows that people can be biased by self-interest without being aware of it. There are so many ways for humans to rationalize their behavior.
There is some innate goodness of people who go into oncology. At the time when most oncologists practicing today made the decision to become oncologists, there was no Chemotherapy Concession. Most of them probably had a personal life experience which created the calling to do battle against the great crab. At the time when people make their most important decisions in life, they are in the most idealitstic period of their lives.
The U.S. government wasn’t reducing payment for cancer care under the new Medicare Modernization Act (MMA) of 2003. They were simply reducing overpayment for chemotherapy drugs, and paying cancer specialists the same as other physicians. The government can’t afford to overpay for drugs, in an era where all these new drugs are being introduced, which are fantastically expensive .
Although the new Medicare bill tried to curtail the Chemotherapy Concession, private insurers still go along with it. What needs to be done is to remove the profit incentive from the choice of drug treatments. Medical oncologists should be taken out of the retail pharmacy business and let them be doctors again.
It’s not that all oncologists are bad people. It’s just that it is still an impossible conflict of interest (i.e. it’s the SYSTEM which is rotten). The solution is not to put the doctors in jail; it’s to change the system. 
2. Jacobson M, O’Malley AJ, Earle CC, Pakes J, Gaccione P, Newhouse JP. Does reimbursement influence chemotherapy treatment for cancer patients? Health Aff (Millwood). 2006 Mar-Apr;25(2):437-43.
3. Love N. Editor’s Note: Phase I study of the “gap”. Patterns of care in medical oncology. 2005; 2(1)
4. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA 2003 Jul 9;290(2):252-5
6. Pawelski GD. Reimbursements Sway Oncologists’ Drug Choices. Online Journal of Health Ethics 2006;1(1)
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