The Antidote

Counterspin for Health Care and Health News

Tuesday, June 12, 2007

Chemotherapy: profits vs. questionable benefits to patients

A story in the NYTimes today reports that oncologists are still trying to find ways to profit from treating their patients with expensive drugs, even though Medicare has cracked down on such profits two years ago (by limiting the markups docs can charge to 6% above the cost of the drug).

Doctors can get around the limitations in reimbursement by simply offering drugs to more patients, whether or not they'll benefit from them.
“There’s pretty good evidence at this point,” said Dr. Richard Deyo, professor of medicine at the University of Washington and an expert on health care spending, “that there are plenty of patients for whom there’s little hope, who are terminally ill, whom chemotherapy is not going to help, who get chemotherapy.”
Some doctors claim that the Medicare limitations are going to result in a lack of access to needed drugs for patients in rural areas, for example, although an unspecified federal commission cited by the article found this not to be the case.

In such a climate, how common are honest conversations between doctors and patients about the risks and benefits (not to mention the costs) of chemotherapy in terminally ill patients? I'd like to see studies on utilization of chemotherapy in settings where oncologists can't profit from use of the drugs (and I'm not sure where those are, given multiple payers, including Medicare, available in most care settings in the US), compared to those where they can. The extra-credit part would be comparing real health outcomes - not 5-year survival! - in different settings.


At 1:46 PM, Anonymous Anonymous said...

Coming rather late to the party here...

I had cancer when I was in my 30s and currently belong to an online discussion group for people who have/had cancer and their family or caregivers.

There is a real mindset of fighting the disease tooth and nail. There is a lot of talk of "hope" and "miracle," even when it's clear someone has more or less exhausted most of their tx options.

Society admires patients who are fighters. When treatment fails and someone dies, it is viewed as losing a battle, as if death is somehow optional rather than inevitable for all of us.

What is the difference between giving up and letting go? At what point does hope turn into acceptance of the inevitable? It is hard to tread that fine line, because we don't always know where the line exists.

Sadly, I think oncology teams also aren't very up front about what cancer tx actually entails. In discussions with me and in reading the patient literature I was given, I found that many of the side effects were downplayed. (This was in the mid-1990s and I think the available information has expanded significantly since then, thanks to the Internet.) But I think there is still an issue of not wanting to frighten patients with too much negative information... and the result is that patients and families aren't always given the tools to make realistic decisions about their tradeoffs. How many people might opt against aggressive, last-ditch tx if they had a clear, honest idea of what it was going to entail?

I do think the communication needs to be honest. Physicians need to get better about having these conversations... but I've seen how it's often an uphill battle when patients/families don't want to face the facts or have bought into the notion that it is better to go down fighting than to gracefully let go.

The latter is an issue of societal values, and I'm not sure how this might be changed.


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