The Profit Motive for Over-Treatment

There was an interesting abstract at the recent AUA meeting. They found that the US VA system is the only one that has significantly adopted Expectant Management (EM) (Active Surveillance for Stage I or Watchful Waiting for those with lower life expectancy/higher co-morbidities). They found no trend towards adoption at comprehensive cancer centers, teaching hospitals or community hospitals in spite of all the data on over-treatment. The VA is unique in the US in that there is no financial incentive for a doctor to give unnecessary treatments.

I'm surprised this didn't get more media attention.

the researchers said...
PERSISTENT UNDERUTILIZATION OF EXPECTANT MANAGEMENT FOR PROSTATE CANCER LAST DECADE IN THE UNITED STATES

Matthew Maurice; Hui Zhu

Abstract: 220
Introduction and Objectives
Expectant management (EM), including active surveillance and watchful waiting, is a strategy to minimize prostate cancer overtreatment. We examined the pattern of its usage in the United States (US) over the past decade and identified factors that affected its adoption.

Methods
The National Cancer Database (NCDB) captures about 70% of all newly diagnosed cancer cases in the US. We queried the NCDB from 2000-2009 for prostate cancers managed with no first course therapy, i.e. EM. Specifically, we examined the trend of EM usage by cancer-risk group, age group, number of co-morbidities, and practice setting.

Results
Overall, EM usage remained stable at 7.5-9.8% from 2000 to 2009 with a similar trend across low-risk cancer (stage 1) and elderly (≥70 years) groups. The Veterans Affairs (VA) hospitals had a significantly higher and increasing (19.7% to 30.8% from 2000 to 2009) EM rate, compared to comprehensive cancer centers, community hospitals, and teaching hospitals, which showed no trend of increased adoption (Figure 2). On further analysis of the VA system, increased EM use was noted for stage 1 cancer (53.7%), age ≥70 years (27.9%), or ≥2 co-morbidities (26.9%), a pattern not shared by other practice settings (Figure 3).

Conclusions
The use of EM did not increase in the last decade overall or at third party payer practice settings, even in patients with low-risk cancer or advanced age. Conversely, the VA led the US in its adoption, especially for those with low-risk cancer or limited life expectancy. While the driving force behind this practice pattern is likely multifactorial, our analysis suggests that the type of reimbursement system may play an important role in EM adoption. This possibility needs to be explored further to minimize prostate cancer overtreatment.

Here's the link:
PERSISTENT UNDERUTILIZATION OF EXPECTANT MANAGEMENT FOR PROSTATE CANCER LAST DECADE IN THE UNITED STATES

I'd be curious to see what the numbers are at Kaiser and other HMOs. No incentive for treatment there, either.

David (Purg)-

I think you are raising an interesting alternative hypothesis to the mercenary reason or maybe an additional reason for the much higher rates of expectant management at the VA. There is no question that we as patients are complicit in this. Do doctors take advantage of our initial "cancer hysteria," or is it we who insist upon radical treatment because of it? Maybe the soldiers who are treated at the VA are different from the rest of us in some ways.

I was interested to see the recently announced clinical trial at MSK & Mt. Sinai to investigate this. They are trying to "evaluate the impact of anxiety and the inability to tolerate ambiguity
on the decision making process in men with prostate cancer who are eligible for active surveillance and their partners/close allies. All participants will be administered a set of questionnaires that assess psychological and affective functioning, and treatment preferences." It seems that they are also perplexed at the low level of AS adoption.

Decision Making for Active Surveillance in Prostate Cancer Patients and Partners/Close Allies

My locally owned Cancer Centre was bought out by. a Natl. chain, Christus, last year. the first thing that I noticed was that my thrice yearly Lupron injection cost was doubled from $7,000 to $14,000. Quite an increase when the cost of Lupron hadn't moved. the clout of K Street Medical lobbying is tremendous, Medicare and BC BS just pated the bill and I was out nothing though I did call my Sentator's office to complain. All for naught. . . . Q

quincy17 said...
My locally owned Cancer Centre was bought out by. a Natl. chain, Christus, last year. the first thing that I noticed was that my thrice yearly Lupron injection cost was doubled from $7,000 to $14,000. Quite an increase when the cost of Lupron hadn't moved. the clout of K Street Medical lobbying is tremendous, Medicare and BC BS just pated the bill and I was out nothing though I did call my Sentator's office to complain. All for naught. . . . Q

That really is astonishing. The cost of the 30mg Lupron injection (known as Lucrin here) here is $36-10 (for all who require it). It is covered by our PBS under the Universal Health Scheme. Cost to the PBS is $1450 for the 30mg injection i.e. $4350 p.a. Even when charged $7000 p.a. in the US, suppliers sure are having a lend of those in need. At $14,000 you could fly to Australia 3 times a year, holidaying in the South Pacific each time for a couple of weeks, pay full price ($1450) for your injection, fly home and still have money in your pocket.

www.pbs.gov.au/medicine/item/8877F
Bill

I'm not nieve enough to believe there is not a profit motive driving doctors' decisions.
Not all doctors of course, but a significant percentage of them. How else do you explain urology groups buying radiation machines and other doctors buying into surgical centers. Doctors are also human and when they can't meet office payroll or have personal debts to pay off their decisions are certainly influenced, especially when a third party is responsible for payment rather than the patient.

Having spent the last 30 years of my working life in accounting and financial positions, I have no problem agreeing with JohnT's last post. It still comes down to business, still comes down to the all might bottom line. It would be naïve to believe anything else in my opinion.

I was one of only 7 state Finance Directors for the SC Dept of Special Needs, and even though we were a "non profit" on paper, it was always the bottom line. What we called "surplus" was simply profit. I learned a lot of terrible ways that the very people we were serving were getting hosed from one end to the other, and this was before the start of the current Great Recession. I had to walk away from that "business" to keep my conscious clean.

david in sc

there was a thread on this forum some time ago showing how doctors could make more from recommending some AS protocols than surgery. All those biopsies, scans and so on really started to add up with some people having primary treatment on top of that.

www.healingwell.com/community/default.aspx?f=35&m=1898684


If doctors were driven by long term revenue then they probably would push AS.



Regards,

An

Post Edited (An38) : 6/17/2013 6:33:06 AM (GMT-6)

good point, Alf.

That's another valid reason why comparing America to Europe doesn't work. In America everyone is contantly suing anyone, it's a sport. Not like that in Europe. That's why when you go to a doctor here with some symptom or the other they always run you through an whole battery of tests.

I once passed a kidney stone and they saw very minor traces of blood in my urine. They had me do sonograms, an MRI, a cystoscopy, follow up visits and then told me that it's not abnormal to have very minor traces of blood in urine and that they ran all the tests just to be on the safe side.

I couldn't agree more Alf and Davidg. In this litigious society, a doc is risking everything by not actively treating a patient. Juries are standing by, willing and ready to convict the doctor if the AS patient suddenly is found to have advanced prostate cancer. In the other thread currently running about complications of DaVinci surgery, we see quite clearly that even an outstanding track record offers little protection against catastrophic claims of harm.

My brother just retired last week after a career as an OB/GYN. He would have continued working, I think, were it not that he feared that this late in his career some grossly overweight, diabetic, high blood pressure, chronic cigarette-smoking patients whom he advised never to great pregnant would eventually sue him and win when the pregnancy she was not supposed to have suddenly went bad. He would never phrase it that way, but I will. He was one of the most caring, competent doctors I can ever imagine, but the level of worry was definitely there.

I'm not sure we can understand a physician's mindset on this without actually being in their shoes, so to speak.

Well, between the profit motive and the fear of litigation combined, it would be hard for any doctor to do anything other than what we see before our eyes. My oncologist (2 plus years now) knew about my ongoing litigation against my RO/Radiation clinic from day 1, and it has never hindered him in treating me or trying to dump me as a patient. Both he, and my urologist, have produced letters to various attorneys of mine the past 3 years to help me on my case. I can only assume they feel no risk or guilt in assisting me.

I remember recently when I saw the infamous dr. "k", after looking over all my scans, he said, "I have never seen so much radiation damage down there before. Whoever did this to you, you should sue them for every cent they have." Odd coming from a doctor, and I never once told him of my ongoing litigation nor did I bring up the subject. He said that on his own.

david

Years ago, when I was still on the faculty at my university, I got to know one of the university's physicians through the Faculty Club. Really nice guy, friendly, outgoing. Then he told me one day, rather somberly, that he was being sued by a patient over what seemed to be a very trivial matter.

Trivial it was, and it was quickly dismissed by the court as it turned out, but following that lawsuit I could see a very perceptible change in that doctor's personality. He became much more cautious, withdrawn, less trusting, and perhaps even a bit more cynical, and I imagine this carried over to his dealings with his patients. It was obvious that the lawsuit experience had had a pretty profound negative effect on him, and I think he stayed that way.

I guess we have to remember that doctors have some pretty special challenges to deal with, and when their careers and/or financial lives are threatened, they will take whatever steps they deem necessary to protect themselves, including ordering all sorts of tests, etc., if they have come to believe that sort of thing is a shield that they need.

Ziggy9 said...

Phenom said...
I'd be curious to see what the numbers are at Kaiser and other HMOs. No incentive for treatment there, either.

I'll attest to that. I have a friend who was dx a year ago with Kaiser. He's a gleason 3+4=7with a slow rising pSA about 6.2 I think it was 5.5 6 months ago and they are fine with his doing AS for awhile. But they are also telling him he's not eligible for seeds because his prostate is too big Although they haven't told him how big it was at the biopsy and not a word about possibly shrinking it with drugs which is SOP many other places before biopsies at times and treatments. He also has no idea the percentage of his positive cores. They seem to be pushing the multi visit IMRT because he's rejected radical surgery. That had nothing to do with me. I think he should find out if they even offer seeds and go that route with medicare. I volunteered to go with him but his girlfriend didn't want me there so fine they both went there clueless and let themselves be persuaded and bullcrapted IMHO. He's just turned 65 and is at the stage that maybe he'll do nothing. Brings back memories when I had Kaiser in the 1980s. I remember for about 2 years I never used my healthcare much but when I did I only talked to a nurse or a physician's assistant. When a few month later I'm taking my dog to the Vet it dawns upon me my dog always got to see a medical doctor but I never did. I switched my healthcare away from Kaiser next open period and never dealt with them again.

Not completely sure what your point was, Zig, I just thought it might be instructive to compare systems with and without incentives for more treatment. I don't want to start a pro-and-con Kaiser thread here, but my experience with them has been nothing like you describe. I see doctors for a problem, not nurses or PAs. In 2+ years, I have never detected a hint of limiting treatment for the purpose of cutting costs. The urologists all recommended surgery but also referred me to both Brachy and radiation specialists. Kaiser's new Mid-Atlantic megafacilities are spectacular, and they get the absolute best ratings for all national health care providers from Consumers Reports. You can look that up. For a self-employed guy like me, having navigated the health care nightmare in this country for 50 years, I'm thrilled to be under their umbrella and have few complaints.