Does Money Impact Cancer Doctors??

This video provides an in-depth exploration of how financial incentives, specifically the fee-for-service (FFS) payment model, influence the decision-making of cancer doctors. Dr. Eric Bricker, referencing a meta-analysis led by Dr. Aaron Mitchell from the renowned Memorial Sloan-Kettering Cancer Center and published in JAMA Oncology in 2019, highlights a critical disconnect between physician self-perception and observed behavior regarding financial motivations. The core premise is that FFS inherently incentivizes doctors to perform more frequent and more expensive tests, procedures, and treatments.

The discussion begins by establishing the prevailing preference among physicians for the FFS model, with 73% favoring it, while a significant majority (69%) oppose alternative payment structures like bundled payments. Paradoxically, only a mere 3% of doctors surveyed believe that money impacts their clinical decision-making. To investigate this discrepancy, Dr. Mitchell's team conducted a meta-analysis, synthesizing findings from 18 specific studies focused on oncology across various cancer types, including prostate, breast, lung, bladder, and colon cancers. This rigorous methodology aimed to provide a comprehensive view of the financial impact on treatment choices in a highly specialized and critical medical field.

The meta-analysis yielded two significant findings that underscore the influence of financial incentives. Firstly, it revealed an increased ordering of radiation therapy when oncologists' practices owned the radiation facility. This is attributed to doctors receiving not only the professional fee for their services but also the facility fee, thereby increasing their overall remuneration. Secondly, the study found that oncologists tended to prescribe more expensive chemotherapy drugs. A compelling example cited was the chemotherapy drug irinotecan, used for colorectal cancer. Its usage was high until it became generic, at which point its prescription rates significantly decreased, suggesting a preference for higher-priced, non-generic alternatives that typically offer greater financial returns to the prescribing physician. Importantly, the study clarified that financial incentives did not appear to influence the fundamental decision of whether to administer chemotherapy at all, but rather which type of chemotherapy or how much radiation was prescribed. The video concludes by emphasizing the American Medical Association's ethical stance against ordering unnecessary procedures for financial gain, yet ultimately acknowledges the "unrealistic" expectation for physicians to practice "blind to incentives," asserting that doctors, as humans, inevitably respond to financial drivers.

Key Takeaways:

• Fee-for-Service (FFS) Incentives: The FFS payment model inherently incentivizes healthcare providers, including oncologists, to perform a higher volume of treatments, tests, and procedures, and to opt for more expensive options, due to direct financial remuneration tied to each service.
• Physician Perception vs. Reality: While a vast majority (73%) of doctors prefer FFS and only 3% believe money impacts their decisions, a meta-analysis of oncology studies demonstrates a clear influence of financial incentives on treatment choices.
• Impact of Facility Ownership: Oncologists whose practices owned radiation therapy facilities were found to order more radiation therapy, indicating that the ability to collect both professional and facility fees directly influenced the frequency and extent of treatment recommendations.
• Preference for Expensive Chemotherapy: The study highlighted that oncologists tended to prescribe more expensive chemotherapy drugs. This practice is linked to payment structures where physicians may receive higher remuneration for administering higher-cost medications.
• Generic Drug Impact: A specific example with irinotecan for colorectal cancer showed that its prescription rates decreased significantly once it became generic and less expensive, further illustrating the financial preference for higher-cost, non-generic options.
• Decision to Treat vs. Treatment Type: Financial incentives did not appear to influence the fundamental decision of whether to administer chemotherapy, but rather the type of chemotherapy prescribed and the extent of radiation therapy utilized.
• Ethical Considerations: The American Medical Association's ethical guidelines state that physicians should never order unnecessary tests or procedures for their own financial gain or that of an associated facility, underscoring the tension between financial incentives and patient welfare.
• Human Response to Incentives: The study concludes that "expecting physicians to practice blind to incentives is unrealistic," emphasizing that doctors, like all humans, respond to financial drivers, which is a crucial factor for understanding healthcare economics.
• Challenges in Payment Reform: The widespread preference for FFS among doctors and opposition to alternative models like bundled payments highlight the significant challenges in reforming healthcare payment systems to align incentives more closely with value-based care.
• Market Dynamics for Pharma: For pharmaceutical and life sciences companies, understanding these financial incentives is critical for commercial operations, market access strategies, and the development of AI solutions that predict prescribing patterns or support sales, as physician behavior is not solely driven by clinical efficacy.

Tools/Resources Mentioned:

• JAMA Oncology: The medical journal where Dr. Aaron Mitchell's meta-analysis was published.
• NCBI (National Center for Biotechnology Information): Referenced as a source for the study (specific link provided in video description).

Key Concepts:

• Fee-for-Service (FFS): A payment model where services are unbundled and paid for separately. In medicine, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, not the outcome.
• Meta-analysis: A statistical analysis that combines the results of multiple scientific studies. It aims to identify patterns, disagreements, or other relationships among studies.
• Bundled Payments (or Episode-Based Payments): A single payment for all services performed to treat a given condition or to provide a given procedure, often over a specific period. It is designed to incentivize coordination and efficiency.
• Capitation: A payment arrangement for healthcare service providers where a fixed amount is paid per patient per unit of time, regardless of the number or type of services provided.
• Professional Fee: The payment received by a physician for their direct medical services.
• Facility Fee: The charge by a hospital or clinic for the use of its facilities, equipment, and staff, separate from the physician's professional fee.
• Generic Chemotherapy: A chemotherapy drug that is no longer protected by patent and can be manufactured and sold by multiple companies, typically at a significantly lower cost than the brand-name version.
• Remuneration: Payment for services rendered or work done.

Examples/Case Studies:

• Radiation Therapy Facility Ownership: The direct correlation between oncologists owning radiation therapy facilities and an increased tendency to order radiation therapy, driven by the ability to collect both professional and facility fees.
• Irinotecan for Colorectal Cancer: The specific example of this chemotherapy drug, which saw a decrease in prescription rates once it became generic and less expensive, illustrating the financial preference for higher-cost medications.