Would You Buy a Used Car From This Man? Part I
Hmm…there’s an eye-catching headline for an oncologist…wonder what they mean by this…
“Payment methods do not seem to affect whether doctors favor chemotherapy over other treatments, the study’s authors said. But once they decide to use chemotherapy, the current payment system appears to prompt some doctors to use more expensive drugs. The authors wrote, ‘Providers who were more generously reimbursed prescribed more costly chemotherapy regimens to metastatic breast, colorectal, and lung patients.”
RED ALERT! RED ALERT! Hit the brakes, Myrtle! Go to DEFCON 1, Commander! Put out an APB for a middle-aged man in a white coat…he is armed with a black tube and small flashlight! Danger, Will Robinson, danger!
So using more costly “chemotherapy” drugs increases the reimbursement to the “provider,” eh? This “study” therefore implies that since using cheaper treatments lowers the revenue paid to an oncology practice, the doctors have a conflict of interest and are biased toward giving “expensive” treatments rather than “cheap” ones. Could there be another possible reason for such a pattern, or is this simply another example of an egregious dereliction of the altruistic spirit the anointed demand in order to save mankind from itself?
“Because there is little evidence that one chemotherapy drug works better than another, ‘the physicians have more control over the agents chosen,’ one of the authors, Joseph P. Newhouse, a professor of health policy and management at Harvard, said in a press review.”
That statement, ladies and gentlemen, raises the hackles of the corporate owners, foreign investors and political comrades of this blog, not to mention all our friends in the olive oil business, if you know what I mean. In rebuttal, let me recite some statistics comparing one “chemotherapy” drug to another in the treatment of the three cancers mentioned in the article, using the outcome of overall survival as a measurement of effectiveness of each regimen, then let the reader decide which treatment they would prefer to take. These statistics refer to patients with metastatic disease for which cure is not possible:
Lung Cancer (non-small cell)
cheap regimen: etoposide/cisplatin; median overall survival (MOS) - 9 months
costly regimen: paclitaxel/carboplatin/bevacizumab; MOS - 17.7 months
Breast Cancer
cheap regimen: cyclophosphamide, doxorubicin, fluorouracil; MOS - 12 to 24 months
costly regimen: docetaxel, vinorelbine, bevacizumab, trastuzumab, et cetera; MOS - at least an additional three months, but we suspect the MOS is on its way to 3 to 5 years based on early data
Colon Cancer
cheap regimen: fluorouracil/leucovorin; MOS - 12 months
costly regimen: oxaliplatin/fluorouracil/leucovorin/bevacizumab; MOS - 22 months
Now if we are not particularly interested in prolonging our life by all means we should ask our oncologist to give us the cheapest anti-cancer treatment available; in fact, using the reductio ad absurdum, in order to avoid wasting our country’s precious financial resources we actually should decline to be treated at all. Now there’s a way to save Uncle Sam some serious dough!
This reminds me of a parable - the story of the publicity crisis at Smiling Joe’s Used Car Lot, but that will have to wait until part two of this post, as I have a plane to catch. Until then:
Stand tall, look ‘em straight in the eye, smile and show ‘em you’re not afraid of anything!
those are some really healthy metastatic lung cancer patients; mos 17 months! LOL
Comment by mushareff hagi akber — March 23, 2006 @ 7:53 pm
Four years metastatic breast cancer. Past two plus years on bi-monthly Taxotere. Last scans: NED
My oncologist doesn’t penny-pinches with my life. He’s worth his weight in gold.
Comment by Tracy — March 23, 2006 @ 9:06 pm
A co-author of that paper is described as a professor of health policy and management at Harvard.
It would be difficult to find an ethereal researcher more remote from a boots-on-the-ground oncologist seeing patients in real life.
“Here’s my opinion. Now, let us get the facts that fit!”
Comment by John J. Coupal — March 24, 2006 @ 4:29 am
Thanks for that. I get so tired of all the cancer patients who can become so cynical about the vast conspiracy of oncologists and pharmaceuticals and how they’re all really just motivated by greed. Why are people so paranoid? The latest one is some circulating e-mail I’ve gotten half a dozen times in the last year- supposedly written by a nurse who was diagnosed with ovarian cancer. That’s a tough one. Diagnosis often comes late. But this e-mail details how the CA-127 is a standard (and at low cost) test for ovarian cancer, and that women aren’t told about it. The e-mail suggests that women are being overlooked, and that they should be asking for this test at every OB/GYN visit. Now, I’m no nurse, but that seems incredibly irresponsible to use this type of emotionalism to get women all hyped up and paranoid about their doctors hiding stuff from them, or intentionally not ordering bloodwork that they need. Every time I get that e-mail I reply to everyone on the long list of people who also got the e-mail, and let them know that CA-127 is not a screening tool for ovarian cancer, and has a 20% false negative rate if used as that. I also try to remind them that they should be able to trust their doctors, and that if they were having medical problems that were concerning, the doctor would order the tests that he/she felt were necessary. Geeesh! Some of these same paranoid people are ones who swear by homeopathic/herbal remedies (some of which are very bizarre). It’s not that I don’t think that stuff has value. It’s just that these dogmatic folks also tend to be the ones who think that the cure is found in some common substance, and it’s being hidden from humanity because it can’t be patented for profit. More and more studies are coming out (bona fide scientific ones) that are demonstrating that many of the natural treatments are contraindicative. I, for one, would like to live in a world where I believe that the pharms really do want to help people stay healthy and maintain a quality of life, where docs enter their profession because they truly want to help people reach their optimal health. Even imaging the world that these paranoid, cynical people live in makes me feel very sorry for them……….
Comment by Aimee — March 24, 2006 @ 6:05 am
…did I states that right? false negative? er, em. 20% of women who have ovarian cancer never have an elevated CA-127 level.
Comment by Aimee — March 24, 2006 @ 6:08 am
There is a lot of public policy research out there that just amounts to whining about why things are the way they are.
Why not do a real study. You could take a cohort of oncologists and give them a financial incentive to use cheaper medications and see what happens. My bet is that the doctors will choose the new regimens anyway in most cases.
At any rate, the time-worn argument that doctors prefer expensive treatments over cheap ones is partly the fault of public policy. A child who has ADD can spend hours in therapy learning to control his behaviors ($$$$) or five mintues a month in a doctor’s office getting a prescription for Ritalin (pennies). No wonder doctors and patients choose the latter. Then of course we primary care docs get it in the teeth for overpresribing Ritalin. Never you mind that the whole reimbursement system is set up for such quick fixes.
Comment by mchebert — March 24, 2006 @ 4:48 pm
In response to your editorial on oncologists favoring more expensive chemotherapy regimens because of a potential increase in revenue, I just wanted to say, kudos to you for stating the truth, that physicians/oncologists are more concerned about patient outcomes than the bottom line.
In the past four years, I lost my mom and dad, brother-in-law, and advisor to various forms of cancer. I am currently a medical student with plans on pursuing fellowship training in hematology/medical oncology following my internal medicine residency; I have become weary of the tired stereotype that the only reason I, and those physicians who came before me, have chosen to go to medical school is the financial reward.
Comment by Brian — March 26, 2006 @ 12:04 am
Our local oncologists seem to worry if they are going to break even on drugs. What is the guy that wrote this paper smoking? Do they think I choose an expensive suture over a cheaper one based on price alone? Has anyone up there ever heard of value? Idiots.
Comment by John Di Saia MD — March 27, 2006 @ 5:44 pm
Give me a break; the study stated the obvious and backed up it’s contention regarding little practical difference in effectiveness with citations to literature. BTW, the reports only called out the breast cancer differences and the low cost regime included none of the drugs your list had.
How often when you ask the waiter for a recommendation do they suggest one of the most expensive, if not the most expensive item on the menu? Does every waiter do that? Would they recommend something they did not like? The answers to these questions are obvious. This study and similar studies compared academic oncologists to community oncologists.
Is anyone suggesting that academic oncologists are less effective or less interested in their patients because they use cheaper regimes. If anything, this is a rare exception since in most studies (i.e. surgical patients or NICU) the academics overutilize healthcare dollars in heroic efforts that yield little practical effect.
Comment by elliottg — April 11, 2006 @ 9:12 pm