Gardiner Harris, the New York Times
Years 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.
But 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.
And 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
The doctors acknowledge
that it would not be ethical to switch to more toxic therapies based on a
change in reimbursement rates.
"But 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.
Next year, their letter
warns, they may refuse altogether to treat Medicare patients, who make up
a large portion of those suffering from cancer.
Similar 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 doctors.
Medicare 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.
"These letters seem
to be scare tactics," said Leslie Norwalk, acting deputy
administrator of the federal Centers for Medicare and Medicaid Services.
Officials 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.
Dr. Siegel said he and his
partners had "thought long and hard about sending that letter."
"In 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 crybabies."
The 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 them."
Bill 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
"Her getting cancer
was a big enough blow," Mr. Cohn, 74, said. "Then it seemed like
politics were working against us, too."
Doctors 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.
Oncologists 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.
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.
Responding 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.
"We 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?"
Some 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
Musa 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."
This 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.
While 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.
"I 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
Yet Dr. Peter D.
Eisenberg, an oncologist in
"We 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."
The 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.
On 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.
"I 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."