A Very Open Letter from an Oncologist

     During the holidays, I received the letter below from Dr. Peter Eisenberg, Medical Director at California Cancer Care, an oncology practice in Northern California.  A member of The Century Foundation’s Working Group on Medicare Reform. Eisenberg is a very experienced, and successful oncologist, who has served on the board of the American Society of Clinical Oncology and the Association of Northern California Oncologists.


     One of the things I admire about Eisenberg is that he pulls no punches.  In the extraordinarily candid letter below he criticizes a health care system that pays physicians  fee-for-service for “doing more” in the form of ever more aggressive treatments.  


     Sometimes they are effective. Often they are not. Meanwhile, the same system pays little or nothing for what some call “thinking medicine”—consulting with other doctors, counseling patients, giving them choices, and offering services that recognize patients as human beings.


     “Medicare pays just $69 for a 15 minute office visit with an established patient; $103 for 25 minutes and $138 for a 40-minute visit,” Eisenberg observes. “As you might imagine” he adds, “even if our doctors saw back-to-back patients 10 hours a day, we would not generate the kind of dollars from evaluation and management fees on our Medicare population to pay more than a fraction of our costs, including rent, salaries for our large staff and our new electronic medical records.


     But Eisenberg does not just blame “the system.”  He recognizes that all of us—doctors and patients, not to mention insurers and Pharma—help perpetuate a system that, too often, values the most expensive and aggressive treatments over patient “care.”  In our society, patients play a role; we expect that everything can and should be cured.  Or, as Eisenberg put it: “we expect that we can smoke 2 packs a day for 30 years and the doc will ‘fix it.’”


      In the eye-opening  final section of this letter, Eisenberg talks, very specifically about the “financial inducements” that lead many oncologists to decide which drugs to use—and  how frequently to administer them—based, not on what is best for the patient, but on what will maximize the physician’s reimbursement.



Dear Maggie:


     I have been working on this since you asked me some questions about our practice.  Maybe it is more than you asked for, but I thought that I’d put my answers in context.  Just the other day Stanford University’s Alain Enthoven wrote on the Opinion Page of the New York Times that we docs ought to be salaried. Though for 30 years I have practiced fee-for-service medicine, had a wonderful career and lived comfortably, I cannot argue!  The waste associated with the inherent conflicts of interest in fee-for-service medicine is more than we can afford.

     At the same time, the way reimbursement is set up, oncologists couldn’t stay in business if we were not paid fee-for-service for selling chemotherapy drugs and services.  Some estimate that up to 70% of our earnings come from the sale of chemo drugs. 


      Maggie, as you know, oncologists are not paid to collaborate with their patients or with other doctors. Listening to patients and chatting with them, asking other docs about a patient, going to conferences, e-mailing experts about problems and looking up stuff in a book (old way) or the net (new way) are not billable events. 


      Neither is sitting for half an hour at lunchtime with our nurses, medical assistants, research director and the other docs in our office to go over tomorrow’s patients, field questions about problems patients have called in, and converse about problems a patient is having.  Can you imagine what this daily meeting costs in terms of salary?  Can you imagine why others don’t do this?

Oncology is a team sport and there is evidence that collaborative practice—not only with the patient and her family, but with other docs who are caring for her as well as smart others who bring different areas of expertise to the table, can provide better care.


     Do you want to go to a doc and be treated according to his treatment plan after an hour-long visit?  Or would you rather that he present your case, along with the pathology slides and the imaging studies, to a group of other docs representing a number of disciplines (medical, surgical and radiation oncology, diagnostic radiology, pathology, nursing, social work, dietetics, pain control,  pulmonary, gastroenterology, etc.) to be viewed and discussed? 


     Smart docs are not afraid to consult with the smarter (or more experienced) docs at the university and even send patients there to get their treatment if the care is complicated and not well–known to us.  But there are plenty of docs who, for one reason or another, choose not to refer their patients to another institution.  Of course there are plenty of patients who would rather get their care closer to home, but  as a recent article in PLOS pointed out,  the doctor has an obligation to inform the patient that he might well get better care elsewhere.


      We also are not paid to remember your name. Our office has a large staff because we try to serve the folks we care for. As a result, we have two nurse practitioners, one research person, and six clinical folks assisting our six doctors.  Our 8 nurses and nurse practitioners  plus 16 full-time staff members  (medical records, front office receptionists, clerks, insurance specialists, patient care coordinator, and a CEO earn a total of  $125,000 a month  .


      At one of our yearly retreats, we had Rachel Ramen, the author and friend of our practice, talk to us about service.  We learned about the notion that one needs to find out where our patient is and start there.  Our care of a patient begins before we even meet them in person.  Before the appointment, Thomas, our new patient coordinator, spends 20 to 30 minutes chatting with the prospective patient on the phone  obtaining all kinds of information, orienting her to our practice and explaining what to expect.  It is not unusual for a new patient to ask me to meet Thomas at her first visit to thank him for his kindness .


     Our front office ladies—there are 4 of them; one answers the phone, the other 3 greet and check out patients—know the name of each patient and their family members.  They give each person a big hello when they arrive.  This might seem silly, but almost every day a patient or family member tells me how great our front office staff is.  I recently read an article that talked about how important it is to, not only honor a patient’s informed wish for treatment, but to respect her as a person.  Patients really don’t want to be numbers.


      After a patient is seen by the doc—we do the initial consultation– the Nurse-Practioners see folks in follow-up.  And there begins a relationship between the patient and our office staff that is as intimate and as close as you can imagine.  With anxiety being appropriately and understandable high, patients have all kinds of questions and concerns that we can’t and haven’t anticipated. 

Our medical assistants spend literally the entire day on the phone solving problems.  Our small hospital census—5.2 patients a day—is a result of our following through on patient concerns and seeing them in the office before problems become ones that can only be solved in the ER or hospital.  We often use the office as an emergency room, but much more conveniently for our patients and at a much lower price..


     It is certainly possible that we are not as efficient as we could be.  Our patients receive very speedy responses to their needs.  It is possible that the system just cannot accommodate the level of care that we provide at the current cost.


     I should point out that the only folks who can really generate revenue are the physicians, nurse practitioners, and the nurses who provide chemotherapy.  Folks in the front office, our medical assistants and the hoard of employees who also “care” for our patient’s cannot bill for the services they provide.

Neither can I bill for innumerable phone calls and tasks I perform at my desk, when I am not sitting face to face with a patient.  Similarly, e-mails to other docs asking for advice or coordinating care among other disciplines go unpaid.


      The reason oncologists have been able to grow a practice as large as ours and provide the level of service we do is because of the revenue we obtain from selling chemotherapy drugs and services. 


     Meanwhile, the Medicare fee schedule that reimburses us for the drugs themselves has been cut. We are paid just 6% over the actual sale price (ASP.)  And since we are not a 1,200 doctor practice like US Oncology, we do not get the discounts or rebates that they receive from drugmakers.  In our case, sometimes the Medicare reimbursement is actually less than what we have to pay for the drug. For instance, we actually lose about $200 every time we give a shot of Neulasta, a drug to increase white blood count and prevent infection in patients receiving chemotherapy.


         But we are paid more for administering the drugs than we were in the past, so it makes economic sense to administer them more often. Not every doctor is willing to do that. The practices that shows some restraint and don’t treat everyone who walks through the door with chemo are the ones that are suffering.

       The truth is that there is no clearly effective chemotherapy for a distressing number of  malignances.  In those cases, if I find that first line therapy  isn’t working, I won’t automatically offer a second type of chemo.  Instead, assuming the patient wants a frank appraisal of her condition, I’ll explain the realistic goals and options available.  In my experience, and in the community in which I live, patients seem to want to know as much as they can about their illness, even if the news is bad.  Delivering terrible news is difficult, time-consuming and extraordinarily painful for all involved.  But good decisions depend upon an honest and forthright discussion and providing the patient with the information and tools to make decisions.


     I have told patients, “I know that I can make you sick, but I am not certain that I can make you better! . . .   In the foreshortened time that you have left, you need to think about what you want to do. Do you want to spend that time in this office, with me and my staff, or is there someplace else you would like to be, something else that you would like to do?”


     It has taken me a while to sort out how I feel about the drugs we use. I began practicing in the late 1970s, and I remember the increasing role and influence of chemotherapy. As more drugs became available, with more evidence that they were effective, our optimism increased –and use increased as well.

     It became clear to many physicians—consciously or not–that selling chemotherapy was really the business they ought to be in as we were compensated so very well for it.  The time one spent with patients was not compensated nearly as well.  This is not unlike the rewards bestowed upon those who perform operations (at least historically), pass tubes into orifices (GI) or make holes for tubes (cardiology & orthopedics), purchase and use their own imaging machines etc.


       When doctors are paid to “do more” there is always the potential for conflict of interest. Keep in mind that physicians are human beings  with the same kinds of responses to financial incentives as everyone else.  Despite our training and promise to put our patient’s interest first, we succumb to incentives that often come in the form of more revenue. 


      As time went on and science grew, we became increasingly more successful in providing chemotherapy that actually worked, and it was a lot easier for doctors to sell chemotherapy than it was for them to spend the kind of time necessary to give patients choices.


       Keep in mind that in the late ‘70s and ‘80s there was not much discussion about “shared decision-making.” If a patient had cancer, and we knew that tumors responded to a certain chemotherapy regimen by shrinking, physicians assumed that patients would choose to take it, if it was offered to them.  “You have cancer, you need chemo,” seemed to be the mantra.

It was not until much more recently that the notion of quality of life, and the fact that just because we shrunk a tumor doesn’t mean that people will actually live longer, was clear to us.


      Nevertheless by the mid 1980s it occurred to me that selling chemotherapy was not a sustainable business plan. I thought that insurers would figure out that margins on drugs were too high and cut reimbursement. With that in mind, in 1990, I established the Association of Northern California Oncologists (ANCO).

I hoped that ANCO could rally docs around the idea of evidence-based medicine and take our science and good results to the insurers, who, seeing the wisdom of our arguments, would reward us for being so scientific, thoughtful and restrained.  Boy, was I naïve!  It seemed that docs  so valued their independence—and made so much money — that they would not rally around anything.


     In the late 1980s, I went to a Clinical Practice Committee Meeting of our professional society and asked them to consider establishing guidelines for treatment.  At the time, I was consulting for Blue Shield of California and was impressed with the wide variation in treatments for similar conditions.  I was told under no uncertain terms that my comments and recommendations weren’t welcome!


      From the insurance side, there also wasn’t much interest in decreasing wide variations in how doctors treated similar malignancies. I suspect that insurance companies have an easier time making it more difficult for docs to get paid rather than investing in innovative ways to collaborate with physicians.  Moreover, if insurers put time and money into researching the most effective treatments, those guidelines would become public—and would benefit competing insurers. 

Ultimately, the job of insurance companies is to pay claims.  My sense is that they either pay them or not,  and holding up payment is what they know how to do.  It would have been nice both for insurers and physicains to agree on treatment pathways, but it didn't happen.


       Some years later, in the mid ‘90s, I sponsored a meeting of 50 N.California oncologists for a weekend. We had speakers representing folks doing quality studies and electronic medical records and the insurance industry, but no docs really waned to compromise, merge practices and establish standard treatment plans.  


       Why is there so much variaion on how much treatent is given for similar conditoins?

\         If you ask doctors you’ll hear a variety of answers. Here goes:

n  Patient and family expectations.  Sometimes, I hear docs say the equivalent to “the patient made me do it,” when justifying the administration of futile chemotherapy.   But it is my experience that patients almost always want to be told the truth about their illness and its treatment and prognosis.  Patients want to be offered reasonable and realistic options for treatment and they rarely choose treatments with a very small chance of success.

n  Societal expectations.  We expect that we can smoke 2 packs a day for 30 years and the doc will fix it. And when, through no fault of their own, people develop cancer,  many feel certain that it must be curable. Maybe too much of Dr. Kildare and Welby.  We just aren’t as good as they are!

n  The doctor’s ideal as healer.  After all, why did I go to med school if not to fix people?  In fact, my earliest memories of contemplating medicine come from the 1950s when I was single digit years old.  I remember thinking that there is nothing medical people wouldn’t do or spend to help a sick person!  I really did think that!  Stuff was cheaper then, and we didn’t have as many choices  of treatment!

There is lots of hype about new treatments.  I can remember as a young oncologist, scouring the ASCO abstracts for a new treatment for an illness and being excited about a marginally better drug.  Perhaps it is time and age that has made me more cynical, as many of the supposedly “better” treatments just did not turn out to be more effective

n  Don’t “take away hope!”  The lamest of reasons for treating someone—especially with medicines that make them sick!  Hope exists in many forms and skillful medical folks with time to spend with their patient can present alternatives other than:

§  “Take chemo =  keep up hope,” or

§  “No chemo = no hope!”

     I prefer to re-frame the discussion around realistic expectations and discuss what it is that the patient is hoping for.  Everyone agrees that living forever is not realistic.  And talking about quality of life as opposed to quantity of life gets some traction these days, as patients and families understand Q of L better.


     So, assuming the patient is open to such a discussion, I can then promise to be aggressive in controlling  pain and in managing other symptoms. In the meantime, I will encourage my patient to  live each day to  the fullest–striving to live as well as possible rather than as long as possible.

       However, rationing chemotherapy is not an issue.  If, after being carefully taught that treatment is not very effective and has nasty side effects, a patient wishes to proceed with chemotherapy, I will provide it for her.

n  Real, (but sometimes small) chance of success.  We do have data on many clinical situations; for example we have evidence of the benefit of first line chemo in advanced non-small cell lung cancer.  We know that median survival increases by a couple months. We know that, with treatment, the chance of living a year increases from 15% – 20% to 30% – 40%. 

But it is difficult to explain some of this material, especially to folks with poor math skills, and it is time-consuming, as well


       So rather than making it clear that the average patient lives only a couple of month longer—and that the chances of surviving for a year are less than 50/50,  it is much easier to say, “Yes, you do have a tough disease, but I think we can help you, so let’s start treatment tomorrow!”  


     Of course, treating Hodgkin’s or another curable disease is something else.

      But most of the cancers we treat with chemo are not curable. Doctors need to be paid for the time it takes to explain the potential benefits as well as the downside of chemo—so that the patient can make a decision about how he wants to spend the time he has left.

n  Financial inducements.  This is a really tough item to discuss, let alone prove.  Most of us truly believe that we are doing good and that doing well comes with it. But, I have heard docs say the most incriminating things and do things that are clearly in their own best financial interest.  For example, I have heard doctors talk about:

o   Treating patients with a 2 hour infusion of pamidronate (a generic drug used to treat cancer that has spread to the bone) rather than a 15 minute infusion of Zometa, because one could make $500 more on the generic pamidronate.


Many physicians rationalized the use of the more profitable, but longer infusion drug on the basis that, “we have a business to run;” “we’d lose $40,000 a month;”  “if we don’t do this we will have to close our doors;” and “my patients are mostly Medicare and they don’t mind hanging around the office for a longer infusion – – in fact they are really very fond of our staff and like spending time with them.” 

A small study of 184 patients who were randomly assigned to a two hour infusion or a 15 minute infusion revealed that 92% preferred the shorter infusion.  (Chern, et al,  Supportive Care Cancer, 2004)

·        A physician leader of a drug purchasing group suggested that one might reasonably evaluate regimens to maximize reimbursement.  For instance, for stage IV non-small cell lung cancer, he suggested using cisplatin and etoposide (given on days 1, 2 and 3 of a three week course) rather than carboplatin and Taxol (given once every three weeks).  He argued that there was data to support the use of cisplatin as a better agent than carboplatin and pointed out that Carboplatin’s use was the result of aggressive Bristol-Myers Squibb marketing.  In addition, he noted, using cisplatin and etoposide took advantage of the increase in administration fees since patients would have to come 3 days rather than one day in a three week period.

·        When reminbursement for  Gemzar and Taxotere was  less than cost, it was reported that some practices took these meds off their shelves until Medicare increased payment.  When I asked one doc how he would treat bladder cancer without Gemzar, he said, “I’ll use Taxol, it’s almost as good!”

·        Amgen “bundled” Aranesp and Neulasta, tying rebates for the white cell-increasing drug, Neulasta to a practice’s use of the red cell-increasing drug, Aranesp.  For instance, if a practice used less than 65% of its erythropoietin as Aranesp, it would lose its Neulasta rebate.  A loss of this rebate resulted in the practice’s purchase of Neulasta at $209 more than Medicare pays.  Therefore, if the practice does not buy more than 65% of its erythropoietin from Amgen, it must come up with $209 out of its own pocket to supplement the purchase of Neulasta for its patients.  Amgen capitalized on its perception that physicians will buy products that maximize their reimbursement. This was easier than trying to sell its products based on solid clinical superiority.

·        Sometime ago, we received an e-mail from our “Leukine Sales Consultant” at Berlex who pointed out that if we “move all CSF (colony stimulating factors = meds which increase blood counts) to Leukine” we would “save” $430,000.  While Leukine , like other CSFs,  does increase the white count it is not FDA-approved for use with most chemotherapy regimens and clinical trials have not been done to show its equivalence or superiority to rival drugs


      Maggie, it is my understanding that patients expect physicians to make recommendations based on what it is best for the patient, not what is financially best for the physician.  It is my contention that patients suffering from cancer would be appalled to understand that they could have received a 15 minute infusion rather than the two hour infusion but for the fact that the physician made $500 more per infusion.  (Currently this financial difference has disappeared.)


      I have been trying and trying to find a rationale to support the style of medicine with which I am familiar.  Unfortunately, I think that the incentives are so mis-aligned and the temptations are so great that docs have a tough time making the right decisions.  Look at the increase in diagnostic imaging in those practices that have purchased diagnostic imaging machines.  “We have to feed the beast,” I have heard.


      My simple-minded solution is to re-align incentives so that the docs are paid for doing the right thing.  What the right thing is, of course,  can be open to interpretation.  What patients think is right may be different from what the payer thinks is right.  That gives me a headache!


     But clearly, we need guidelines  for the most effective care – and patients need to know whether their doctors are following the guidelines. Medicare needs to jump on the quality band wagon and support docs’ use of quality programs such as ASCO’s Quality Oncology Practice Initiative (QOPI), a voluntary program that serves to encourage oncologists to examine their practice and to compare themselves to others.  Currently, over 1,500 physicians in more than 400 practice sites are registered and the American Board of Internal Medicine considers QOPI to fulfill an oncologist’s requirement for quality improvement in his recertification.


      Patients also need to understand that as long as Medicare pays fee-for-service there is a potential for conflict of interest. 

     But patients really do not want to hear about doctors’ incentives.  An article in Health Affairs in 2000 (Miller and Horowitz) showed that:


1.     Many patients are unaware of the financial incentives their own physicians face.  Only about half of the respondents wanted information about the incentives.

2.     Trust in physicians is high; 84% of patients completely or mostly trusted their physician to put patients’ interests first.

3.     “Many patients stated that the information was not relevant to them because they trusted their physician. In fact, some stated that they would not want the information because it would raise unwelcome doubts.”

4.     “Patients also expressed confidence that they could judge the quality of their care and could change physicians if they were not satisfied.”

5.     “Many patients stated that they would want to learn if the incentives imposed any cost on them.”

  1. “In general, patients expressed strong reluctance to raise the issue [of incentives] with their physicians for a variety of reasons, including fear of embarrassing or angering the physician; belief that the topic is too “personal” and “intrusive” to raise; perceived irrelevance to treatment; and desire not to take valuable time away from clinical matters.”

      I have a real problem in placing the burden of figuring out whether a doc is looking out for a patient’s best interest on an ill, frightened and anxious patient.  As professionals, we have a sacred responsibility to put patients’ interests first.  


      Ultimately, Medicare may want to reduce the fees it pays “outlier” doctors,, reducing the incentive to over-treat.  Meanwhile, Medicare needs to pay doctors for the time it takes to really explain the  pros and cons of treatment to their patients in depth– so that patients can make an informed choice—and not just give informed consent.

34 thoughts on “A Very Open Letter from an Oncologist

  1. Anecdotal evidence, even from long observation, does not provide a clear enough picture. Those who do the most outrageous things are more likely to be remembered than those who don’t or who don’t even speak up.
    Explaining treatment options to a patient and then expecting them to make an “informed” decision is not realistic. How can a layman make an informed decision when the evidence itself is unclear?
    Some therapies work surprisingly well in a small number of cases, but how does one know if you will be in this category or not?
    It seems to me the gray areas are the ones which are the most troublesome. The pointless therapies for those with terminal illnesses are provided because of the mindset of the US public which wants to live forever. This is not a medical problem, it is a moral one. As such it can’t be fixed by doing cost/benefit analysis.
    I really wonder how many doctors take reimbursement into account when choosing what to do. This seems like an area for some real investigation, although how one would get people to tell the truth is a problem.

  2. I wonder if Dr. Eisenberg could provide an estimate of how much more Medicare would need to pay him and his colleagues in order to provide patients with a complete discussion of their options within a shared decision making context while insuring that the economic viability of their group practice is maintained and sustained. At the same time, if those E&M fees were raised to an adequate level, how much of a reduction in drug utilization might we see? At the end of the day, how big a reduction in outlays would CMS and other payers realize? In other words, would the system save money or not and, if it would, is it worth the fight to make it happen? Hopefully, the answer is yes.

  3. Robert–
    As Peter point out, if you explains the risks and benefits to patients clearly and carefully (and I’m not talking about a 15-minute discussion) most will decide that they don’t want to put themselves through a treatment that offers very, very little hope–or hope of an extra two months of poor-quality life..
    How do we know that Peter is right? Becuase we have years of shared decision-making research involving all sorts of cancers as well as other other diseases. You can read what I have written about shared decision-making here. http://www.healthbeatblog.org/2007/10/shared-decision.html
    It is a process which involves giving the patient a pamphlet that describes risks and benefits in detail, as well as a video starting patients who have faced the choice, describing why they decided as they did.
    Usually, the patient will find someone to identify with in the video–“That’s just the way I feel!”
    The patient takes video and pamphlet home, watches the video (usually more than once) with family, discusses the pamphlet, then goes back to the doctor’s office where a “decisoin-making coach” –a trained nurse-practioner or a doctor– asks him questions to make sue he understands the odds, the risks and benfits . . .(Some coaches use roulette wheels adn other props to help patients understand odds) The coach then asks the ptient to talk about his greatest fears and hopes.
    In the process, the patient eventually voices and sorts out his priorities–and putting that together with what he has learned about risks and benefits–is able to make a decision.
    Shared Decision-Making does not resolve the uncertainties of medicine–but it does allow the patient to grasp the uncertainties, and to make a decison baseed on his temperament, personality and priorities.
    Reserach shows that when patients go through this process very few “regret” their decision. Regret-and
    lawsuits–are much more likely when patients don’t go through this process.

  4. I wholeheartedly agree with Dr. Eisenberg that medical oncologists need to be paid for the time it takes to explain the potential benefits as well as the downside of chemo, so that the patient can make an “informed decision” about how he/she wants to spend the time he/she has left.
    I believe some in Congress had the idea to begin paying medical oncologists more for talking to and listening to cancer patients and less for very expensive, very aggressive treatments. It was called the Medicare Modernization Act (MMA) of 2003.
    The MMA changed how Medicare paid for medical oncologists’ services. It called for rewarding medical oncologists to communicate with patients and to spend more time dealing with patients’ chronic health conditions caused by infusional therapy.
    Medical oncologists would be reimbursed for providing evaluation and management services, making referrals for diagnostic testing, radiation therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival. In other words, being paid to think rather than just dispense drugs.
    Before, medical oncologists received no reimbursement for providing oral-dose therapy to patients. This had been the principal barrier to the availability of oral-dose protocol. The advent of oral agents ultimately meant that medical oncology had to change its identity, prior to the Chemotherapy Concession.
    The MMA bill offered patients benefits they did not have before, mainly coverage for oral chemotherapy drugs. More might have been achieved if ASCO and other fraternal groups had lobbied as much for the oral chemotherapy drug issue as they did for office-practice expense reimbursement. They fought long and hard to retain the Chemotherapy Concession.
    The MMA bill tried to remove the profit incentive from the choice of cancer treatments, which were financial incentives for infusion-therapy over oral-therapy or non-chemotherapy, and financial incentives for choosing some drugs over others. Patients should receive what is best for them and not what is best for their oncologists.
    While the MMA bill was trying to pay medical oncologists for being doctors again, instead of being in the retail pharmacy business, the private payors still go along with the Chemotherapy Concession.
    Medical oncologists try to make a point that the profit they make from selling chemotherapy drugs does not all go into the pockets of the physicians. There are enormous numbers of uncompensated services that are provided to the patients that are not billable and which are not compensated.
    However, after the new MMA bill, they would still be able to provide services. They’d just have less money left over after providing those services. All physicians (indeed all small businesspeople – which is what physicians are) have things they do in their business which are directly profitable and things they do in their business which are very unprofitable but unfortunately necessary.
    Let’s take a simple example: sales and marketing.
    Who is the “customer” of a medical oncologist’s services?
    You might think the patient. True enough. But oncology is also a referral specialty. There is no shortage of medical oncologists. So medical oncologists have to be good doctors, who provide good services, or they will lose their referrals to medical oncologists who provide better services.
    Now, medical oncologists are basically good people who are compassionate and who want to provide good care, in any case. But to imply that medical oncologists wouldn’t provide good care in the absence of being able to make money running a retail pharmacy is just not true. The motivation to supply good care ranges from the altruistic to the selfish (loss of referrals).
    The new MMA bill showed that simply reducing reimbursement for drugs wasn’t the answer to the biggest problems, which are financial incentives for infusion therapy over oral therapy or non-chemotherapy, and financial incentives for choosing some drugs over others.
    Medical oncologists should simply submit copies of their drug invoices and get paid the exact cost of the drugs, plus a small markup for administrative expenses. They should get reimbursed for the costs of actually adminsitering the drugs, plus a small markup which is not enough of an incentive to treat with infusion therapy, rather than just writing a prescription for drugs which would be filled at a pharmacy.
    What still needs to be done is to remove the profit incentive from the choice of cancer treatments. Patients should receive what is best for them and not what is best for their oncologists. Take medical oncologists out of the pharmacy business and force them to become doctors again.
    Selling cancer chemotherapy with concessions creates conflicts of interest for oncologists

    Among the many great sentences here is one that caught my eye
    “I have a real problem in placing the burden of figuring out whether a doc is looking out for a patient’s best interest on an ill, frightened and anxious patient. As professionals, we have a sacred responsibility to put patients’ interests first” says Dr Eisenberg
    I agree in part with that sentiment.
    The dilemma is the ethics of looking out for the good of the individual patient verses the ethics of the health of the “COMMON GOOD”- The latter being a resonable ethical stand to take also from a public health perspective.
    So one person’s expensive chemotherapy denies others of other treatments?
    Respectfully and don’t have all the answers,
    Dr. Rick Lippin

  6. Gregory–
    I think you and Peter are basicallly in agreement–and I am told that quite a few oncologists would like to get out of the drug-selling business and back into the business of cognitive medicine.
    The problem is that no one wants to take a huge in their income. And once someone has set up a practice with as much staff as Peter has, yet only 6 doctors who can bill plus 8 nurses who can bill it would be hard to take a huge cut in revenues and still keep the whole thing running.
    Meanwhile, the individual doctors have homes, children in college whatever–lifestyles based on the income they have been making.
    Peter may be right when he says that the amount of service that his practice offers make not be affordable. On the other hand, he is not practicing cosmetic dermatology. His patients have good reason to be frightened and demanding in the sense of wanting phone calls returned the same day and questions answered. They also are sorely in need of comfort,
    and it sounds as if the personal relationsips provide that.
    What is the anwswer?
    For now, I would say paying oncologists more for cognitive services and trimming the fee for admnistering drugs in a way that would reduce an oncology practices total revenues somewhat–but not in a catastropic way.
    Over time, if it seemed to make sense, Medicare could continue to trim fees for administering drugs, especially if we realize that some are only marginally beneficial. “Benefit to the patient” should be a major factor in how much we pay a doctor for a service. .
    Meanwhile, if oncologists actully followed the entire “shared decision-making protocol”–they or their nurse/decision coaches should be well-paid for their time. It is time-consuming, and an art.
    It’s not just one conversation with the patient.
    And many people could be saved a world of suffering–while Medicare saved money so that it can continue to cover the rest of us– if patients truly have a chance to consider the side effects as well as the possibilty of living two months longer, six months longer, 2 years longer . . .
    It seems to me that, for every individual, the risk-benefit equation is going to feel different. And they need time to think about it, to talk to their
    families. . .People shouldn’t be making these decisions when they are panicked, having just heard that they have cancer.
    There are int’l standards for “shared decision-making”; the videos and pamphlets are updated ever two years, and the state of Washington has passed legislation that makes it difficult for patients to sue if the doctor has actually taken them through the shared decision-making protocol.
    I see this as one answer to malpractice.
    I also think that Peter is right: fee-for-service creates a built-in conflict of interest. Doctors are human. If you tell them, we’ll pay you much more if you “do more”–many if not most will do more. Aferr all, in the majority cases, they honestly believe that this is “probably” best for their patients–even though we don’t have medical evidence supporting many new therapies. But doctors, like everyone else, are exposed to the hype.
    I suspect we would be better off paying oncologists a lump sum for
    taking a patient from first diagnosis to a lengthy remission–or,sadly, death. It strikes me that they should get bonuses for overall patient satisfaction, with an emphais (in the questions that patient and family are asked to answer) on quality of life.
    Certainly oncologists whose patients gain two or three or five more years also deserve bonuses.
    But as Peter knows –and I’m sure you agree–quality of life can be more important than a few more months.
    I particularly like the idea of encouraging patients to think about what how they really want to spend the time they have left–particularly if the oncologist is able to manage pain and other symptoms well enough that the patient really can fulfill his wish.
    For oncologists,I would think that figuring out ways to improve quality of life would be enormously rewarding. Selling drugs is not enormously rewarding–unless they really are helping the patient in a signficant way.

  7. Barry–
    It would be very difficult to put numbers to some of the questions you ask.
    (See my last comment, replying to Gregory on various ways to compensate the oncologist.)
    But chemo drugs are so
    extraordinarily expesnive, that even if Medicare does’t slash what it pays doctors to adminster these drugs, but just consistently lowers that payment-while raising payment for cognitive service–Medicare would save a substantial amount of money because it wouldn’t have to pay for the drugs. And over time, it could realign the financial incentives to favor the patient.
    Then there is the cost of caring for patients whose deaths have been lengthened by chemo–but with a poor quality of life. These patients are likley to die in a hospital–if not in an ICU. Often, these are the most expensive deaths–in terms of human suffering.

  8. I also agree with Dr. Eisenberg that payers and our society value doing things more than listening to patients and discussing important issues with them. If physicians were paid for their thinking skills rather than for selling medications, the use of drugs may fall. Patients and families would receive what they want and need thoughtful discourse and expertise in helping them through some very tough times.
    And I agree with him that patients should know more about the financial implicatons of all of American medicine and make treatment decisions based on what is best for them according to their own medical condition and their personal preferences and expections.
    Cancer sufferers are taking doses of expensive and potentially toxic treatments that are possibly well in excess of what they need. Emerging evidence, brought out in the Journal of Clinical Oncology, showed that many of the highly expensive “targeted” cancer drugs (Herceptin, Avastin and Rituximab) may be just as effective and produce fewer side effects if taken over shorter periods and in lower doses (JCO, Vol 25, No 25; September 1, 2007: pp. 31e-32).
    But pharmaceutical companies seem to be attracted to studies looking at the maximum tolerated dose of any treatments. The study suggested that we make the search for minimum effective doses of these treatments one of the key goals of cancer research. For example, Avastin, used to fight colon and lung cancers, the dose being tested is 15mg per kilogram of body weight, despite other research showing it may work with 3mg per kilogram.
    Everyone is scared to death – and rightly so – at what is happening to the healthcare economic system with these increasingly expensive new drugs that benefit only a small percentage of patients who receive them, hence the headlong rush to develop tests to identify molecular/genetic predisposing mechanisms whose presence still does not guarantee that a cancer drug will be effective for an individual patient. Nor can they, for any patient or even large group of patients, discriminate the potential for clinical activity among different agents of the same class.
    It explains the new paradigm of requiring a compantion disgnostic as a condition for approval of new targeted therapies. The pressure, in fact, is so great that the companion diagnostics they’ve approved often have been mostly or totally ineffective at identifying clinical responders (durable and otherwise) to the various therapies.

  9. I plead ignorance on what Oncology residency and fellowship curriculae look like in 2008/2009 but I would argue for a heavy component of Palliative Medicine in all Oncology training.
    Hoping of course that “death is the enemy to be vanquished at all costs” philosophy does not still prevail among the specialty of Oncology’s academic leadership?
    Dr. Rick Lippin

  10. Gregory D. Pawelski –“There is no shortage of medical oncologists.”
    That should read, “there is no shortage of medical oncologists in San Francisco (or New York City, Miami, Boston, LA, Dallas, Phoenix, etc.)” In large parts of the US there is a shortage of medical oncologists. The same could be said for many other specialties.
    In fact, I am willing to bet that if you superimposed a copy of the Dartmouth Atlas’ map of medical cost effectiveness on a map of the distribution of doctors in the country you would find that there is a near match – surpluses of doctors equal increased costs.
    Presumably that is because the surpluses of doctors lead to the temptation to indulge in poor practice to increase incomes, regardless whether we are talking about clinics, HMO’s, or private practice.
    That is why on a REGIONAL basis there is no significant difference between costs in prospective payment systems, in fee for service systems with doctors salaries, and in straight fee for service systems. Yes, large clinics in the upper Midwest cost a lot less than private practice in NYC, but they also cost a lot less than HMO’s in San Francisco and large salaried systems in Boston. HMO’s in San Francisco do not offer significantly lower costs than private doctors in San Francisco; fee for service systems with salaried doctors in Boston do not offer lower costs (in fact, recent publicity suggests they actually are more expensive) than private practice physicians; and large fee for service clinics with salaried doctors in the upper Midwest do not offer lower costs than private doctors in the upper Midwest (and again, based on information from local health care economists, they actually cost more.)
    Regional differences based on practice patterns and cultures wipe out any potential savings that differences in payment methods theoretically suggest, and a large part of that regional difference appears to be related to numbers of doctors.
    In the communities where I have sat on tumor boards for the last 15 years, oncologists are not engaged in trying to create more work. They are swamped with the work they have, and conversations tend to center on the problem of telling patients there are no useful treatments available, not on what questionable treatments might offer a minimal glimmer of hope. The same is true for surgeons, orthopedists, urologists, gynecologists, and most other specialists. The problem is not to find work, but to find a way to do the work already there. I once had the experience of getting a phone call at work offering a service to help me get additional work. I said no thanks, my problem was getting through the work I had already.
    I do not know the solution to this problem, short of an aggressive and powerful national program of practice standards enforced by the payment system. I do know that the evidence shows that merely changing payment systems does not have the desired effect, in that high payment areas continue to be high payment whether they are served by HMO’s, clinics, or private doctors.

  11. Patrick Schoenfelder. I may add that when the general “boomer” population ages, the incidence of cancer rises, the demand for medical oncologists is rising faster than new ones can be added to the system. There’s a shortage of thoracic surgeons, there’s a shortage of gastroenterologists, there’s a shortage of geriatricians, and a shortage of primary physicians. What physician category is next? I agree, I do not know the solution to this problem either.

  12. Great blog on an issue near and dear to me, a “recovering” oncologist, now full time palliative care physician. My practice spanned the time when oncology was a noble profession to one in which it is largely market driven, leading to enormous salaries–so that in effect, many oncologists are really chemo-therapists, rather than physicians who care for patients with caner. As suggested earlier in the blog, oncology fellows certainly need more palliative care training–there is no ACGME mandated requirement (just as there is no mandate for ICU and other physicians who routinely care for seriously ill and dying patients), but many forward thinking programs do have mandatory PC training requirements, and really good programs send their fellows for extra training in cancer communication skills (Onco-Talk). But these measures alone are far from sufficient to change the culture of chemotherapy practice where it is emotionally easier, and financially lucrative, to administer more chemotherapy, than to have the tough discussions.

  13. I agree with Dr. Eisenberg. I am a physician involved in cancer care (but not an oncologist) and have seen a lot of what Dr. Eisenberg talks about. The incentives are clearly misaligned and the patients in many cases have no real concept of what is going on and what their chances are.
    The typical government and insurance solution – cutting the fees paid to the oncologist for seeing the patients is counter-productive.
    As a country, we waste are BILLIONS of dollars a year prolonging peoples lives by a small amount and improving their quality of life not one bit.
    By the way, Michael Moore had it exactly wrong in his movie Sicko when he castigated the insurance company for not providing an experimental treatment for metastatic renal cell carcinoma. Such treatments are not provided in Canada, England, France and especially Cuba. But getting the facts correct would have cramped his style.

  14. I absolutely agree with the stated conflicts of interest, but there will be new ones if the hospitals have their way. They are starting to buy up all of the physician practices and they will ultimately move the physicians to salaries. But then they’ll add “production incentives” which will pay physicians for increased use of expensive testing and admissions. So instead of physicians having insurers interfere with treatment, hospital CEOs will take their place. And they’ll pressure salaries down and good physicians out by importing lesser-paid physicians from other countries.
    What used to be physicians providing oversight of hospitals, it will soon be the reverse.
    I think physicians should be paid very well, but not on the basis of how much care they do or do not provide. A salaried system solves that but creates new problems if through a hospital.

  15. Gregoy, Rick, Patrick–
    Thanks for your comments.
    Gregory–You’re right, we need to be looking at minimum doses, not just to save money, but to protect patients against being over-treated.
    Rick– I agree. And since Medicare funds graduate medical educaton, I think it should require palliative care training for many/most specialities, with intensive training for specialities like oncology. Every oncologist should know how to control pain.
    While you are right that
    suppply creates demand, it’s not that specialists in areas where there are many doctors “indulge in poor practice to increase incomes.”
    Much of this happens on an unconscious level. Specialists tend to fill their appointment calendars, and since there are no firm guidelines as to how often a cardiologist should see a patient suffering from congestive heart failures, if there are twice as many cardiologists in town A than in town B, the cardiologists in town A will have space in their appointsments calendar to see their patients twice as often.
    The supply of hospital beds also is key.
    If a doctor knows, in the back of his mind, that there are probably beds available, he is much more likely to hospitalize the patient with congestive heart failure. It’s easier to treat her in the hospital and he can call in other doctors to consult. These other doctors then run their own tests and suggest further treatments–so one thing leads to another.
    But the structure of delivery systems also matters. The same Dartmouth reserach that shows such regional variation based on supply also shows that when you drill down and compare delivery systems in a single region you will
    find enormous differences.
    Look at UCLA compared to UCS(www.dartmouthatlas.org)
    You’ll also find that Mayo Clnics are relatively more efficient than average even when located in different regions of the cutlure, though the Rochester Minn clinic is the most efficient.
    Overall, large multi-speciality clinics where doctors work on salary- Mayo, Cleveland Clinic,
    Geisinger, INtermoutnain–
    produce the best outcomes at the lowest cost.
    Medicare will be thinking about using those most efficient systems as benchmarks and rewarding (or penalizing) other systems that do or don’t approach those benchmarks.
    Small fee-for-service practices are, by and large, least efficient. And new data shows that doctors working solo score poorly when continuous medicall education is measure–compared to doctors working in large
    groups. (Note I said, “on average” there are solo praticioners out there who are keeping up, but it’s much easier to do so if you
    are in constant contact with other doctors saying “Did you see that paper . ..?”
    It also is likely that
    Medicare will be offering loan-forgiveness programs to doctors willing to go into certain specialties and locate in underserved regions of the country.

  16. Maggie —
    I agree that the large clinics in the Upper Midwest — Mayo, Marshfield, Gunderson in La Crosse, SMDC in Duluth, MeritCare in Fargo, and several smaller ones — provide the best and most efficient care in the country (looking at their own data I am a little confused as to how the Dartmouth folks decided to include InterMountain, Cleveland, Kaiser, and some others, since they are much more expensive than the Upper Midwest clinics.)
    However, as it turns out ( and this is from a university based health care economist who specializes in the Upper Midwest) the big clinics are consistently the highest cost providers in their own regions. Since Dartmouth collects data by hospital referral district, not by individual providers, they miss that fact. Therefore, Dartmouth is able to compare Mayo Rochester with the Mayo branches, Kaiser LA with Kaiser SF and Kaiser Portland, and USC with UCLA since they use different hospitals and therefore fall into their reporting standard. But they cannot compare private providers and group providers using the same hospitals, and they do not seem to compare private doctors working in Blue Earth Minnesota with group clinics in Rochester and La Crosse.
    As for CME’s — CME data collection is notoriously messy since there are CME’s that consist of going golfing and CME’s that mean attending a week long international scientific meeting. In practicing in two different large groups and in two different private practices over the years, I have to say that I was unable to detect a difference in CME habits between the practice settings, although there were wide differences between individuals in both types of practice settings.

  17. Patrick–
    You are loooking at costs without adjusting for differences in local prices based on differences in cost of living, overhead (real estate and salaries) etc. etc.
    Datmouth adjusts for all of this.
    Also, Dartmouth is not just looking at costs– it is looking at outcomes as well. The best care provides the best outcomes at a lower cost. The fact that some provider in Minnesota provides care at a lower cost than Mayo is not very impressive if their outcomes are poorer (which they are.)
    Have you actually read the Dartmouth Reserach?
    go to http://www.dartmouthatlas.org
    and look at their 2008 Atlas.
    Dartmouth has been doing this reserach for nearly 3 decades and adjust for many factors– underlying health of hte population, race, age, as well as local prices. . They don’t “miss” much.
    The Dartmoth research is considered “the most important health resarch of this century” (Don Berwick, IHI) and the gold-standard for comparative outcomes and efficiency research.
    At this point, no one disputes it.
    See Shannon Brownlee’s book,
    “Overtreated,” for one of many that is based on the Dartmouth Resarch.
    Also, Dartmouth didn’t “decide” to include Intermoutnain. Intermoutnain is widely recognized for value (effective care at lower price.) You also should read about Geisinger– an excellent system and they’ve made very good use of Health IT.

  18. Jack, Legacy Flyer, DAvid
    Thanks for your comments
    We definitely should watch out for hospitals paying doctors “productivity bonuses” to “do more.”
    Legacy Flyer:
    I agree that Michael Moore had his facts wrong in that part of the movie.
    The husband was dying of an incurable cancer–at that stage, there was nothing that could be done.
    The couple was very sympathetic, but what the wife was asking the insurer to do would have been futile. I wrote about his when I reviewed “Sicko” on http://www.thehealthcareblog.com
    Otherwise, the movie was largely true–particularly on health care and patient satisifaction in Candada and France–topics where I’ve done research and have first-hand information.
    Yes, I agree that palliative care training should be required for oncologists –and many other physicians.
    And it is true that it is much easer to recommend chemo than to have the horribly difficult discussion where you tell the patient that there is no cure . . . This is anothe reason oncologists have taken the chemo route.
    It’s not just the money. They were never trained to deal with death and dying.
    How many of us would be up to –and able to–having that discussion with very frightened people, of all ages, who are close to death?

  19. Maggie –
    Yes, I have read the Dartmouth Atlas for 2008.
    Dartmouth does not, in fact, consider regional variation in cost of living, at least not in their current volume. They just use real dollars. They go out of their way to repeatedly make the point that the actual price of procedures and care is not a significant factor in overall cost – the main source of variation is volume of utilization. In fact, they point out that the cost per unit of service is lower at MGH than at Mayo, but MGH is much more expensive because of greater use of services.
    Yes, they do single out Cleveland Clinic and InterMountain as particularly cost effective providers who provide cost effective care in spite of being in higher cost areas. You were right about that. I had forgotten about that because I was just looking at regional performance data, since I was interested in tracking performance of smaller practices.
    Dartmouth makes no comparison of private practice organizations vs. other types of practice. They are not “missing” this. They are just not addressing it at all.
    However, their examples of successful institutions are almost all of large fee for service organizations that pay physicians on a salary or salary plus incentive basis. Some of their examples for high costs are private practice institutions, especially in their detailed study of the LA area, but they do not analyze this factor explicitly, mainly because they are comparing hospitals, not medical practices. Their main focus in the study is on very well known national programs with medical school connections and with strong reputations in order to make the argument that cost is independent of quality and effectiveness, and that in fact there is probably a perverse relationship, with higher cost suggesting lower effectiveness.
    They do make the point that variation in cost occurs back and forth within the same system at different sites despite using the same pay systems and financial models, with one of their more interesting points being that Mayo Scottsdale is actually the most efficient of the Mayo branches despite being in the highest cost of living area and being located in a very high medical cost area.
    In fact, comparing branches of the same systems from area to area shows that Dartmouth’s ignoring cost of living is justified in considering medical costs: UCLA costs more than UCSF despite the fact that COL is higher in SF than LA. Kaiser also costs more in LA than SF, but Kaiser Portland is a lot lower cost than either. Kaiser Portland is more efficient than Group Health in Puget Sound despite very similar cost of living.
    In the end, the Dartmouth people conclude that differences in practice patterns, not dependent on overall structure of practices or on the culture of the overall organization, and not even predictable by the distribution of specialists vs. primary care, are the cause of variation. They strongly believe that the supply of providers and services influences the use of those services.
    They do recommend that coordination of care, medical homes, and high intensity supervision of patients out of hospital through phone contact and other means might be helpful and cost saving. This has in fact worked well in some settings, but unfortunately a recently concluded Medicare pilot program on more intensive daily management of diabetes and congestive failure failed to prove useful in saving money. Supporters of medical home style management, including me, have criticized the study for various reasons, but the outcome suggests that more research is needed before nationwide adoption. A good argument can be made that large group practices and HMO’s are likely to have an easier time adopting these standards than smaller practices.
    Coming back to the main point of this thread – overuse of expensive chemo regimens as a result of financial incentives — in the end, the Dartmouth people suggest that the payment system has to take the lead in making appropriate changes. This is one more argument for a greater role for federal insurance and a lesser role for private insurance, since historically the private programs have been unable to introduce significant controls on practice patterns. In fact, the Dartmouth people suggest that the leadership in this has to come from Medicare.

  20. Patrick–
    First, I very much appreciate the fact that you have read the 2008 Atlas. You clearly take these issues very seriously.
    And I agree that larger medical practices and HMOs are going to be able to do a much better job of proividng Value (better outocmes over cost) than small practices.
    Jack Wennberg (founder of the Dartmouth resarch) agrees with you on this. They looked at solo practices and small practices a long, long time ago. Jack has been doing this work since the 1970s.
    You should go back before 2008 to see that the Atlas adjusts for differences in local prices.
    Secondly–quite apart from my opinion on the Dartmouth reserach (and I’m only one person and not an M.D.) all I can tell you is that the many doctors and medical researchers who have read the Dartmouth reserach over the past 2 1/2 decades would disagree with what you are saying. (It there was such an obvious hole in their calculations, doesn’t it seem likely that someone else would have noticed it by now? What Dartmouth is saying is nwhat powerful elements in the medical establishment do Not want to hear.)
    Perhaps you have spotted holes and weaknesses in the reseachch that no one else has seen. But some very skeptical eyes (the AMA, for instance) have scoured this research looking for a way to say
    that this isn’t true. . .
    If you Google my name and “Dartmouth Medicine” you’ll find more articles explaining the reserach in greater detail. Or, read Shannon Brownlee’s book: OverTreated. Or mine, Money-Driven Medicine.

  21. Maggie —
    I did not say that large practices are better at implementing value, I said they would probably be better at implementing the medical home design, an innovation of as yet unproven value, because of their larger size and the fact that specialists of many types are gathered under one roof. I did say that I believe that trying that technique is a worthwhile experiment. If it works, I would expect it to rapidly spread out into the surrounding communities of providers.
    The Dartmouth people are very specific about the fact that price — reflecting cost of living as well as other considerations — is not a significant factor in health costs, since most variation in health cost is due to differences in utilization than unit costs. Again, their example of MGH vs Mayo is of a provider that charges more per unit of service actually being the higher value provider.
    The controversy regarding the Dartmouth data comes not from any comparison of private practices vs. group practices, but rather from the implicit attack on sacred cows — which are in fact large group practices — such as MGH, UCLA Med Center, and so on. It is very controversial to suggest that places like MGH give less high value care than Marshfield Clinic, since it turns ideas about prestige and quality in medical care on their heads.
    It is very surprising to see that certain clinics in high cost areas — InterMountain, Mayo Scottsdale, Cleveland Clinic — have managed to become high value providers in the face of local culture. That is a great achievement.
    However, given the way that medical training and practice works, it is not surprising to see that in areas dominated by high value providers the general culture is one of high value in all practices, large and small — see data on the Upper Midwest. The large clinics, especially Mayo, are the source of a lot of the medical culture in the area, due to their impact as referral centers, the large numbers of doctors who have trained with them, and the impact of their styles of practice on the general public. The reverse is true, of course, in areas where the dominant players are low value providers.
    It is this kind of leadership that is the greatest impact of the large centers on value, both positive and negative.

  22. Patrick
    The last iteration of the Atlas does reflect a lot of what you are saying, culture plays a very important role in care patterns.
    You did say one thing that I dont concur with:
    “It is very controversial to suggest that places like MGH give less high value care than Marshfield Clinic, since it turns ideas about prestige and quality in medical care on their heads.”
    Actually, I could not disagree more. Not that the recent Globe expose shed new light (there is always baseline mischief), but plenty of folks have never bought in to that canard. What I think you should have said is no one talks about it or educates the public. That is changing, and those that know, know.

  23. Nice post. As a primary care doc, I just have to point something out: while large drug markups certainly created a perverse incentive, they also enabled medical oncologists (who are, like us, cognates rather than procedurists) to establish effective medical homes.
    Wouldn’t it be nice to just pay–in a more straightforward way–for these invaluable cognitive services? It’s the planning and integration of care that are so valuable…much more so than the ridiculous things I need to document to bill a 99214. Yet CMS (and the RUC) assign no value to these services.
    Lesson 1: with sufficient resources, we can provide outstanding care to complex patients.
    Lession 2: Don’t make doctors cross-subsidize from a dubious source (e.g., drug markups) to fund these valuable services. Pay for them directly.
    Lesson 3: When a specialist says he or she needs ridiculous procedural, imaging, or drug reimbursement to cross-subsidize a truly valuable (but uncompensated) service, refer to #2 and remember the harm a perverse incentive can do to patients. Who knows how many patients were (and still are, evidently) harmed by the powerful economic incentive of the oncology drug markup?

  24. Brad —
    We can argue for a long time about which are the most presitigious medical centers in the US, since it is clearly based on opinion. As a midwesterner with 35 years in medicine, I often have not shared people’s perceptions regarding the prestige of various institutions on the coasts, believing them to be based on lack of information, but I have always been aware of them.
    I think the best answer to this question is provided by the Dartmouth Atlas itself. The five institutions they chose to focus on were picked because they were the five leaders on the list of “America’s best hospitals” in US News. The fact that the atlas then finds three of the five — MGH, Hopkins, and UCLA — to offer care of less “value” does overthrow the perceptions that put them on the list. The fact that the atlas then finds that relatively unknown (outside of some health care insiders) clinics in the rural midwest offer greater value of care is so unexpected that it dramatizes the Dartmouth case for the issue of better practice standards for better value care. It has also caused people to tell me that they think the Dartmouth results are “rigged” in some way to “attack” rivals usually thought to be “better” than the Dartmouth system — an opinion I do not share but that does not surprise me, given historical perceptions.
    The Dartmouth studies are actually just one more brick in the wall suggesting that the culture of US health care has led to problems of both cost and quality of care. As has been prevously discussed here, this is a problem that has been solved everywhere else in the developed world by creation of boards to review practice standards and to implement those standards using their payment systems as a means. The Dartmouth evidence, and their proposal to address this problem through Medicare reimbursement, is just one more way of proving that this is true, and also proving that our “unique American solutions” — HMO’s, large multispecialty groups, etc. — are not solving the problem in the country as a whole or in large sections of the country.

  25. Patrick, Brad, doCanon–
    Thanks for your comments.
    doCanon–I agree completely. We should be paying directly, for VAlue (defined as outcomes over cost) rather than encouraging doctors to cross-subsidize their most effective service with less effective more expensive services.
    “Benefit to the patient” should be key in deciding how much we pay.
    Patrick and Brad: On the importance of “culture”: on the one hand, the northwest and part of the midwest (from Washington State to Iowa)does seem to provide a more congenial home for evidence-based medicine and collaborative medicine based on team-work. Non-profit HMOs that actually manage care based on quality, not on price, also have succeeded in this area. (When people say that “managed care failed” they ignore places like Minnesota.)
    But as the Dartmouth Research shows, much of this less profit-driven, more conservative medical culture is tied up with the fact that you don’t have the same excess capacity in Minnesota that you have in other parts of the country.
    In particular UCLA has too many hospital beds and too many doctor–as does Boston.
    When the beds are there, they are filled. (Unncessary hospitalizations– and once the beds are filled, doctors call in specialists to consult, which leads to more (often unnecessary) tests and procedures.
    Recently I was talking to Jack Wennberg (father of the Dartmouth Research) about Geisinger–a medical center that offers very high value (great outcomes at lower cost.) It’s just an extremely efficient high-quality organization –and it’s located in Pennsylvania, which is not
    a state that one associates with high quality, low-cost medicine.
    But Geisinger operates as if it were located in the state of Washington. And this is because it understands the problem of excess capacity. It is currently(or already has) expanded into a new town where there are two hospitals; it is buying both of them, and closing one of them down.
    Jack suggested that if the Mayo Clnic had done that when it moved to Jacksonville, Florida it would have created a setting where it would have been easier to practice medicine the way it is practiced in Rochester, Minnesota.
    If the beds aren’t there, the patients cannot be hospitalized–even if that is what some patients families, or what some local doctors, expect.
    Patient expectations help create a “culture” but patient expectation are driven by what doctors in their area do. Doctors lead; patients follow. IF doctors are profit-drive; and paid fee-for-service they will “do more” –and patients will expect more intensive, aggressive and expensive care. Few patients have read the research which shows that often that leads to worse outcomes.
    Patrick you write that”The fact that the atlas then finds that relatively unknown (outside of some health care insiders) clinics in the rural midwest offer greater value of care . . than Mass General . . has also caused people to tell me that they think the Dartmouth results are “rigged” in some way to “attack” rivals usually thought to be “better.”
    I realize that you do not agree with these people–and that you admire the Dartmouth research.
    But what Brad is saying is that these days (for at least the last 15 years) virtually no one has doubted the Dartmouth reserarch.
    Granted, there are no doubt some 70-year-old doctors who belong to the Massachusetts Medical Society (probably the most conserative state medical society in the country) who question Dartmouth and think Mass General is the top of the heap. But these are the same doctors who either have “never heard of”, or “don’t believe in ” hospice care.
    Not only the medical cognoscenti, but the mainstream press (USA Today, the NYTimes, WSJ, Forbes, etc.) now regularly cites the Dartmouth reserach without feeling a need to quote someone “on the other side.”
    So I agree with Brad that “prestigious” hospitals may seem prestigious to some wealthy dowagers in the suburbs outside Boston or NY but no one inside medicine (including health care journalists) think of Mass General as the equal of the Mayo Clnic, InterMountain, Geisinger or Group Health Co-operative.
    Some of the “brand name” hospitals like Hopkins have become well known because of their reserach–not their patient care.
    I was just reading an excellent article by a Yale law professor who specializes in health law, and he points out that Mass General charges 30% more than other hospitals in its area for the same procedure. The fact that it charges more helps add to its “brand name” power; Americans assume that if something is more expensive, it must be better. Pasquale continues: “Joe Biden’s Chief Economist, Jared Bernstein, has pointed out something fundamental about pricing in a market economy: it can be driven by power as much as by productivity. The story of Partners casts doubt on the efficacy of market-driven initiatives in health care. Consumers appear bewitched by marquee brands which insurers are powerless to bargain with.”

  26. I think the market power of Partners Healthcare, for example, could be mitigated by charging patients a higher co-pay to use them than competing hospitals that can do similar procedures at lower cost with comparable or better quality. Even $500-$1,000 of additional co-pay could be enough to get patients’ attention. In the case of procedures where MGH is designated as a regional Center of Excellence, such as for organ transplants and the like, the co-pay could be waived. For procedures like routine labor and delivery or gall bladder removal and the like, patients should probably go to a local community hospital anyway instead of an inherently high cost academic medical center. Co-pay differentials would help to steer them in that direction.
    More broadly along the same lines, if healthcare generally is more expensive in certain regions on a risk adjusted outcomes basis, perhaps co-pays should be higher in those regions than in places like Minnesota or the Pacific Northwest. You have often questioned why taxpayers in Iowa or Minnesota should have to pay comparable Medicare taxes for overly aggressive practice patterns in Miami or LA or NYC. If patients in the high cost regions had to pay more out-of-pocket, than patients in more cost-effective regions, it would get patients’ attention, and, in turn, the attention of doctors and hospitals responsible for the culture that drive aggressive and costly practice patterns in the first place. This is not a profit vs. non-profit issue; it’s a medical culture issue.
    Finally, in areas with excess hospital capacity, there are numerous instances of hospitals that consistently operate well below economic occupancy rates. Just because the beds are there, it doesn’t mean that doctors will fill them no matter what. If such hospitals require state subsidies to stay afloat, perhaps they should be allowed to fail and close instead. In NJ, at least partly out of economic necessity, we have recently been doing just that.

  27. Perceptions of quality are a very important issue in potential health care reform in the US. A realistic grasp on what those perceptions are for most people is very important in any reform effort.
    Most Americans and most American doctors actually believe that US health care is the best in the world, end of argument. Citing data from study after study that demonstrates otherwise does not phase them, since they believe the data is simply false, created to defend the poor socialistic health care people get outside the US. “Everyone wants to come here,” is their mantra.
    Inside the US, most people believe that the best health care is available in certain well known institutions on either coast. Read the methodology that US News uses to concoct their list of “America’s Best Hospitals.” It is based on two things — the performance of “exceptional” medical treatments, meaning new, rare, and experimental procedures, and a poll of “200 leading specialists” in each area of medicine they analyze.
    People who really care about health care in the US are familiar with the Dartmouth Data, the comparison data with foreign health systems, and agree with everything we have all been saying on this thread. However, most people and most health care professionals are not aware of or do not agree with a lot of the facts this data supports. No hospitals covered by Marshfield Clinic, Gunderson Clinic in La Crosse, SMDC in Duluth, or MeritCare in Fargo are even included in the US News ratings. Regions Hospital in St. Paul, the flagship of Health Partners, the most important HMO player in the Twin Cities, is not rated in a single service area. These are the institutions that Dartmouth singles out as amoung the best providers of high value health care, but for most Americans both in and out of medicine they are below the radar.
    People tend to believe what they want to believe, and for doctors and citizens in Boston, LA, NYC, Baltimore, etc. that includes the belief that their beloved local sacred medical cows are the best darned health care facilities in the world. Unfortunately, that opinion is not limited to 70 year old doctors and Boston dowagers, but is shared by the general public and most doctors in the areas as well as — and this is important — most doctors trained in the areas. To suggest to them that residents of some wide spot in the road in the middle of Wisconsin or some cheese eating Frenchmen have better health care than their beloved institutions offer is heretical in the extreme.
    That is why a National Health Board, to remove discussion of health care and these kind of issues from the realm of opinion and put it in the realm of science, is so important.
    BTW — Maggie, you are right that HMO’s have succeeded in the Twin Cities, as they have in Seattle, Portland, and the Bay Area, to a degree that they have not been able to elsewhere. Everything in Minnesota, as Garrison Keiler would point out, is above average. But one of the noticeable things about Minnesota’s HMO’s is that they cost more, not less, to deliver care than the surrounding fee for service large clinics and smaller practices in the rest of the state. This has little to do with the cost of living, which is similar in the Twin Cities to Rochester for example, but more to do with the fact that the Twin Cities is the only place in Minnesota — in fact the only place between Milwaukee and Billings — where there are surpluses of doctors and hospital beds.
    In the end Maggie, Ezra Klein, the NY Times, the LA Times, etc. etc. are performing an invaluable service in getting the word out about what is true and what is not true. Unfortunately, the US is full of people whose reaction is to discount everything they say as “biased” and turn to the Drudge Report, Ann Coulter, and Fox news.

  28. Barry and Patrick–
    thanks for your comments
    Barry- I totally agree that a co-pay of $500 to $1,000 for certain hospitals that are very expensive, but no better for routine care hospitals, would be enough to get the attention of middle-class patients–and cause them to ask why the co-pay is so high.
    And, as you , say the co-pay could be waived if the patient was going in for a very difficult procedure and the hospital was a designated Center of Excellence in that area.
    On charging higher co-pays in certain regions where Medicare spends more , while that would be fair, I doubt it would fly in Congress.
    The regions that overtreat-Massachusetts, New York, New Jersey, Maryland, California, Florida etc. are very powerful states.
    In this recession economic necessity may well force us to close some hospitals–and as long as this happens in areas, like New Jersey, where we have too many hospitals, that would be a good thing. (New York City also has had too many hospitals, though recently we closed some . . .Massachusetts has too many as does Florida . . . )
    Yes, a great many Americans do cling to the idea that we have the best health care in the world.
    My perception that many people realize that U.S. New & World Report’s list of the “best hospitals” is simply a device to sell magazines may be partly due to the fact that I live in New York. New Yorkers tend to be pretty skeptical about things like that.
    And because both the New York Times and the WSJ have been quite good about writing about overtreatment, and the Dartmouth research for a number of years, they have reached a fair number of people. . .
    At the same time there are many New Yorkers who believe that our hospitals are the best (unless they or a relative has spent a week or more in one of them).
    When you talk to people who have been in the hospital in recent years you rarely hear a
    happy story. Patients and families are shocked by how hectic things are; how often mistakes are made; how hard it can be to find a nurse, how often patients are allowed to suffer agonizing pain, and how high the bill is even when you think you have insurance
    . . .
    Most people in our hospitals are working very hard, but too often they have too much to do, the systems are not there to support them (the health IT in the ER doesn’t talk to the health IT in the rest of the hospital), and the administration’s priorities are skewed.
    toward cosmetics that will attract Park Avenue doctors and their well-heeled patients.
    In general, my guess is that younger, better-educated and more progressive Americans
    recognize that our health care system is broken.
    I definitely agree– we need a national health board, that is insulated from Congress and lobbyists- to deliver evidence-based information about our system.

  29. The present system is still an impossible conflict of interest. Let’s take a look at what is done with drug selection in cancer treatment.
    The American Society of Clinical Oncology (ASCO) say 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 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.
    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?
    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.
    A 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.
    So ASCO’s Dr. Bailes maintains that drugs are chosen only on the basis of “clinical evidence.”
    Well, 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.
    Although oral tyrosine kinase inhibitors, like Tykerb, offer patients a well-tolerated, conveniently administered alternative to intravenous (IV) therapy, Decisions Resources, one of the world’s leading research and advisory firms for pharmaceutical and healthcare issues, found that oncologists are yet ready to use Tykerb as a replacement for Herceptin.
    Ninety-one percent of surveyed oncologists stated that intravenous (IV) cancer therapies are more profitable than oral therapies. And fifty-eight percent of oncologists say they would favor IV Herceptin over oral Tykerb because administration of IV drugs remains an important source of income for their practices. Selling cancer chemotherapy with concessions still creates conflicts of interest for oncologists.
    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 testing the cancer biology.

  30. Oncologists are often broken down by specialty relating to their forms of treatment or the type of cancer they treat. Some of the specialties include gynecologic oncology, pediatric oncology, medical oncology, radiation oncology, and surgical oncology. For patients who are suffering from incurable cancer, oncology can still offer the benefit of reduced symptoms and side effects, as well as psychological and emotional support, help finding social services, and more. This is referred to as palliative care.

  31. A private practice oncologist told me years ago about a patient of his. The oncologist takes his vacation at the end of August. The patient was supposed to come in for chemotherapy on Wednesday, the day before the oncologist left. The patient couldn’t make it. The oncologist, therefore, did what he always did in that situation, wrote a prescription to be “filled” at a nearby, large, comprehensive, NCI-designated cancer center. Had the patient received treatment in the office, the oncologist would have received $6,000, which the oncologist said was very generous. The NCI-designated cancer center, however, billed $28,000, and was paid 75% of this amount. (The oncologist knows about the large disparity between what the NCI cancer centers get and what he gets). I thought this was very revealing.
    In 2007, NCI launched the Community Cancer Centers Program, a three-year pilot phase of a new program that is supposed to help bring state-of-the-art cancer care to patients in community hospitals across the United States. The program is designed to encourage the collaboration of private-practice medical, surgical and radiation oncologists, with close links to NCI research and to the network of 63 NCI-designated cancer centers principally based at large research universities. Wed the NCI-designated cancer centers with the community cancer centers. NCI-designated cancer centers are a very large business which act as a base of power for academic clinical oncologists who made a mess of clinical cancer research, since the time Nixon first declared war on cancer. http://blog.aperio.com/articles/Fortune_Cancer.pdf

  32. I really wonder how many doctors take reimbursement into account when choosing what to do. This seems like an area for some real investigation, although how one would get people to tell the truth is a problem.