ago, doctors hospitalized cancer patients before giving them chemotherapy,
so worried were they about the retching, dehydration and weight loss that
the drugs could cause. Now, most doctors treat cancer patients in their
offices, allowing them to return home quickly or even go to work.
the federal Medicare program is changing the way it pays cancer doctors,
and some oncologists are so angry that, hoping to turn patients into
lobbyists, they are warning patients that they face a return to
hospitalization and nausea.
, doctors in a practice called Oncology Associates wrote a letter recently
to their patients saying that because of the new reimbursement system,
patients might have to "switch to older medications."
though those drugs "may be more toxic or less convenient for
you," the letter said, "we will be financially unable to give
chemotherapy medications which cost us more than the reimbursement."
To get proper care, patients might "have to be hospitalized," it
added, though "this approach will likely not be usable due to the
large number of patients and limited facilities."
doctors acknowledge that it would not be ethical to switch to more toxic
therapies based on a change in reimbursement rates.
if Medicare makes it impossible to do what we've been doing, then I don't
know what to do," said Dr. Robert Siegel of Oncology Associates.
year, their letter warns, they may refuse altogether to treat Medicare
patients, who make up a large portion of those suffering from cancer.
letters are being delivered to patients around the country, according to
oncologists, advocates for cancer patients and the American Society of
Clinical Oncology, the nation's largest professional society of cancer
officials have denounced some of the letters as alarmist and untrue,
saying that on balance, the changes in reimbursement this year - which
lower payments for cancer drugs but raise payments for administering them
- provide more money to oncologists.
letters seem to be scare tactics," said Leslie Norwalk, acting deputy
administrator of the federal Centers for Medicare and Medicaid Services.
of the American Society of Clinical Oncology said that Medicare's payments
to cancer doctors this year are about equal to those last year.
"Essentially, I think it's correct to say that it's been a wash in
the aggregate," said Deborah Kamin, senior director of cancer policy
and clinical affairs at the society.
Siegel said he and his partners had "thought long and hard about
sending that letter."
the year leading up to this prescription drug bill," he said,
"we had decided not to scare our patients. They are dealing with
enough issues. But the truth of the matter is that we were just not
listened to. There is this sense that you're just overpaid
doctors, he said, decided to write the letter so that patients could
"become advocates for their own care." For now, Dr. Siegel said,
"we have told our patients that we will continue to care for
Cohn, whose 70-year-old wife, Jan, is being treated for colon cancer at
Dr. Siegel's clinic, said that the letter scared the two of them. They
worried that Mrs. Cohn would not be able to get the drugs her doctor
ordered, or that she would have to go to the hospital instead of a
doctor's office nearer their home.
getting cancer was a big enough blow," Mr. Cohn, 74, said. "Then
it seemed like politics were working against us, too."
in many specialties complain that Medicare underpays them. The program
sets prices for most aspects of care delivered by doctors and hospitals,
and many say they have no choice but to accept what Medicare sends.
long avoided cuts forced on other specialists because the government
allowed them to bill Medicare for cancer drugs in amounts that often far
exceeded their actual costs. The system was widely criticized by watchdog
groups; in a 2001 study, the General Accounting Office found that doctors
were able to get discounts as high as 86 percent on some drugs.
pharmaceutical companies even marketed drugs to doctors by emphasizing the
profits to be made. TAP Pharmaceutical Products, a joint venture of Abbott
Laboratories and Takeda Chemical Industries of Japan, agreed in 2001 to
pay $885 million to settle federal charges that it conspired with doctors
to bill the government for free samples of a cancer drug, Lupron.
to insistent calls for change, Congress changed the reimbursement system
late last year as part of the legislation creating a limited Medicare drug
benefit. Lobbyists for oncologists, among others, opposed the changes -
the lobbyists arguing that they would devastate cancer care.
did not like the old system," Ms. Kamin of the American Society of
Clinical Oncologists said, "even the perception that it set up
inappropriate incentives we did not support. The question is: How do you
change it so that you don't take resources out of the system so that you
cripple the ability to deliver care?"
studies suggest that American oncologists overuse cancer drugs,
particularly in the last months of patients' lives after the patients have
failed to respond to other treatment. While oncologists say that some
patients demand such care, advocates for cancer patients say that
Medicare's reimbursement system encouraged overtreatment.
Mayer, a breast cancer survivor and the author of several books on the
subject, said, "If oncologists are making most of their money off the
markup on drugs, then that favors the overuse of drugs."
year, Medicare has lowered payments for drugs but more than doubled
payments for office expenses. To come up with fair payments, Medicare
officials are using surveys of practice expenses generated by Ms. Kamin's
society. "We're using ASCO's own data," Ms. Norwalk, the
Medicare official, said.
drug payments have fallen about 10 percent on average, reimbursements for
administering drugs in oncology offices have doubled, Ms. Norwalk said. To
ease the transition to a new system, Medicare is paying an additional 32
percent, or about $60 an hour, for office services.
want to pay the physician the right amount to keep the patient in the
physician's office," Ms. Norwalk added, "and I'm sure that's
what patients want."
Dr. Peter D. Eisenberg, an oncologist in
, said that his 11-doctor practice laid off six people on Friday,
including a full-time massage therapist and a social worker. The practice
still has a human being answering every call instead of a machine; it has
a full-time patient coordinator who spends hours scheduling care for each
patient. Some of those services may have to be scaled back, which will
inconvenience people, he said.
provided a Nordstrom level of care that was funded by these outrageous
drug markups," Dr. Eisenberg said. "Now, reimbursements are
going down to Kmart levels, and we can't provide the level of service our
patients have become accustomed to."
, another oncologist, Dr. Jack Keech, wrote a letter to his patients in
December warning that "some services that we have provided in our
office in the past will no longer be available to you in our office."
Dr. Keech said his letter is being used by the Association of Northern
California Oncologists as a model for other cancer doctors.
payment system will change again next year, when Medicare will base drug
reimbursement on surveys of average drug sales prices. Ms. Norwalk said
Medicare would soon publish the prices it expected to pay, and oncologists
would have two months to comment on the figures before they became final.
She marveled that some doctors were already complaining.
average, oncologists made $310,371 in 2002, according to surveys by the
Denver-based Medical Group Management Association. But Dr. Siegel of
Oncology Associates said he foresaw disaster.
make a good living doing what I do, and I would not deny that there isn't
some fat in the system that could potentially be cut," he said.
"But in 2005 and 2006, they're not taking a scalpel to the system but
a sledgehammer. They are going to destroy the integrity of this."