Cancer Patients' Dilemma: Expensive Pills Vs. Invasive Chemo Treatment

Greg Pawelski

Over the last two decades, office-based oncology practices derived most of their revenues from treating patients with chemotherapy. The practices were compensated both for delivering the drugs and for the drugs themselves. The Journal of the National Cancer Institute (JNCI) stated that private-practice oncologists typically derive two-thirds of their income from selling chemotherapy.
Reimbursement of any kind was often lacking with oral-dose drugs because the patient purchased them directly. The oncologist simply would write a prescription and the patient would go to a pharmacy and obtain the product. There were no administration fees for office-based oncology practices unless they also dispense the drugs, because there was no involvement in their purchase.
An oncology practice would realize almost no revenue from those patients who are treated entirely with oral-dose agents. The core activity in medical oncology was the provision of infusional chemotherapy. The entire structure of office-based practice revolved around this activity and was what distinguished medical oncology from most other specialties.
Under previous law, Medicare covered chemotherapy for cancer patients, but did not pay for oral-dose anti-cancer drugs, unless they were available in both oral and injectable form. Medicare Part B covered a total of seven oral-dose anti-cancer drugs, under this provision. Older Americans were being denied access to the latest generation of cancer drugs simply because these therapies came only in pill form.
Oral-dose chemotherapeutic agents are easy to use and offer the promise of less frequent visits to the physician’s office and their infusion rooms, or even hospitals. This promise is not trivial, especially as we have come to realize that many forms of cancer may be managed with these drugs, especially when they offer the equivalent outcome as intravenous drugs.
The fact that medical oncologists received no reimbursement for providing oral-dose therapy to patients had been the principal barrier to the availability of oral-dose protocol. The advent of oral agents ultimately meant that medical oncology would need to change its identity, prior to the chemotherapy drug concession.
Under the new Medicare Modernization Act of 2003 (MMA) medical oncologists were 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.
Because oral-dose drugs ultimately delivered on their promise of combining equally efficacious therapy with better adverse event profiles and easier administration, they rightfully gain their appropriate share of the marketplace, again.
However, the new Medicare bill still had major flaws, in that it continued to provide incentives to administer chemotherapy, in the same way that surgeons have a financial incentive to recommend surgery. And it still allowed medical oncologists to recommend treatment on a “trial-and-error” basis.
When clinically relevant and accepted drugs may have the same efficacy, and a tumor is “resistant” to one of them, it is within the standard of care to give the drug with the least “resistance” and/or the drug with the most “sensitivity.”
My personal belief is in having additional support of drug patient-specific activity as determined by extensive cell-based laboratory pre-tests to bolster the clinical justification of the drug(s) chosen, with no economic ties to outside healthcare organizations; recommendations made without financial or scientific prejudice.
I think the key is to begin to paying oncologists (and other specialists) more for talking to and listening to patients and less for very expensive, very aggressive treatments.
Over the last 20 years, there has been a lot more per capita abuse of chemotherapy, in terms of cost benefit ratio to the system and toxicity benefit ratio to the patient.
It’s up to us to make a difference by speaking out, in fixing those aspects of all of this which have gotten broken along the way. If medical oncologists were paid for their thinking skills rather than for selling medications, the use of drugs may fall.