In his Health Care Renewal blog, Roy M. Poses MD describes a New York Times article about financial incentives affecting physicians. Excerpts below.
The New York Times recently reported on research suggesting the susceptibility of physicians to financial incentives. The research, and how it was reported, illustrate the complexity of untangling issues of conflict of interest affecting physicians and other health care decision makers.
To summarize, the Times reported on a study just published in Health Affairs that found "providers who were more generously reimbursed prescribed more costly chemotherapy regimens to metastatic breast, colorectal, and lung cancer patients." The Times noted that "unlike other physicians, cancer doctors can profit from the sale of chemotherapy drugs in a practice known as the chemotherapy concession." So, "while critics say this creates a potential conflict of interst among oncologists advising patients on treatment, the doctors have said that the profit is needed to pay the high cost of running their practices." The Times then quoted opposition to the notion that physicians' decisions were ruled by conflict of interest from an "executive" [actually, Interim Executive Vice President and CEO] of the American Society of Clinical Oncology, Dr Joseph S Bailes, who said words to the effect that "cancer doctor select treatments only on the basic of clinical evidence." The Times then interviewed the study's senior author, Professor Joseph P Newhouse of Harvard, who argued that "there is little evidence that one chemotherapy drug works better than another, [so] 'the physicians have more control over the agents chosen.'" Bailes countered that "there was clear clinical evidence about which drugs should be used even in advanced stages of the disease and that doctors recommend the most appropriate treatments." But Dr Craig C Earle, another study author, had the last word, arguing that "doctors, despite their insistence that their treatment decisions are based solely on what is best for the patient, are affected by payment policies and other financial influences, including gifts from drug companies...."
So what really is the message, that physicians make appropriate decisions based on the evidence, or that they are influenced by financial incentives, including gifts from drug companies? The Times reported the research results in the context of a tit-for-tat among the articles' authors and the ASCO CEO. By giving the authors more air time and the last word, the Times seemed to slightly favor their point of view.
So maybe this is all another argument for what I have said before about conflicts of interest: I suggest developing a broad set of principles about conflicts of interest, and generally about business ethics in health care, focused on all transactions with outside organizations with their own vested interests or agendas. These principles should apply to all who make decisions in health care, physicians, other health care professionals, and leaders of health care organizations. The details of the implementation of these principles could vary, so as to apply to the setting and role of each individual.
For what it's worth, my gut feeling is that most physicians try to make decisions based on evidence, on patients' characteristics and their preferences, but that it is hard not to be influenced by other factors, including financial incentives.
I should also note that the only financial incentives the study analyzed were Medicare reimbursement rates. Conflicts of interest, such as gifts by pharmaceutical firms to physicians, may affect their decisions, but this study was not designed to assess such conflicts. Hence Dr Earle's last comment may reflect his beliefs, and may be true, but does not follow from this single study's results.So maybe this is all another argument for what I have said before about conflicts of interest: I suggest developing a broad set of principles about conflicts of interest, and generally about business ethics in health care, focused on all transactions with outside organizations with their own vested interests or agendas. These principles should apply to all who make decisions in health care, physicians, other health care professionals, and leaders of health care organizations. The details of the implementation of these principles could vary, so as to apply to the setting and role of each individual.
Drug Selection in Cancer Treatment
The American Society of Clinical Oncologists (ASCO) says oncologists should make chemotherapy treatment recommendations on the basis of published reports of clinical trials and a patient's health status and treatment preferences.
How about published reports of clinical trials?
More chemotherapy is given for breast cancer than for any other form of cancer and there have been more published reports of clinical trials for breast cancer than for any other form of cancer.
According to NCI's March 31, 2006 official cancer information website on "state of the art" chemotherapy for recurrent or metastatic breast cancer, it is unclear whether single-agent chemotherapy or combination chemotherapy is preferable for first-line treatment. At this time, no data support the superiority of any particular regimen. So, it would appear that published reports of clinical trials provide precious little in the way of guidance (1).
In the total absence of guidance from published reports of clinical trials then, what basis are treatment regimens selected instead? ASCO says that this should be further based on a patient's health status and patient treatment preferences.
So what is being done?
Recently published in the journal Health Affairs is a joint Harvard/Michigan study entitled, "Does reimbursement influence chemotherapy treatment for cancer 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 (2).
A March 8, 2006 New York Times article described the study. One of the more interesting aspects of the story was a comment from an executive with ASCO, Dr. Joseph S. Bailes, who disputed the study's findings, saying that cancer doctors select treatments only on the basis of clinical evidence (3).
So ASCO's Dr. Bailes maintains that drugs are chosen only on the basis of "clinical evidence."
Yet, Dr. Neil Love reported in a survey of breast cancer oncologists based in academic medical centers and community based, private practice medical oncologists. The former oncologists do not derive personal profit from the administration of infusion chemotherapy, the latter oncologists do derive personal profit from infusion 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 (who are motivated to keep off-protocol patients out of their chemotherapy infusion rooms to reserve these rooms for on-protocol patients) 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 commuity-based oncologists, only 18% prescribed the non-remunerative oral-dose drug (capecitabine), while 75% prescribed remunerative infusion drugs, and about 40% prescribed the expensive, highly remunerative drug docetaxel (4).
There are patients who have progressive disease after first-line therapy, only to enjoy a dramatic benefit from second or even third line therapy, and these patients would have been much better served by receiving the most probable active treatment "the first time around."
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 Cell Culture Assay Testing (a test to pre-identify which chemo drugs would benefit the patient). While being faced with a large number of choices of otherwise equally acceptable therapies, oncologists select the treatments which generate the most income for private practices or generate the least inconvenience for the clinical research institutions.
In the absence of Cell Culture Assay Testing, oncologists will continue to base their drug selections on reimbursement more than on any other single factor. Absent assay testing, they are free to choose the most remunerative therapy (5).
By utilizing Cell Culture Assay Tests, they do so either because they want to choose the treatment which is most likely to work or that is what their patients want. Afterall, even ASCO endorses "patient's treatment preferences." Either way, they are forced to consider information going beyond reimbursement.
Sources:
(1) http://www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page8#Section_297
(2) http://content.healthaffairs.org/cgi/content/abstract/25/2/437
(3) http://www.nytimes.com/2006/03/08/health/08docs.html?ex=1145160000&en=584b5c2aa35995a3&ei=5070
(4) http://patternsofcare.com/2005/1/editor.htm (figure 37, volume 2, issue 1, 2005)
(5) http://www.positivehealth.com/test/articles.asp?i=1832
Posted by: Gregory D. Pawelski | June 16, 2006 at 03:37 PM