Medicine is a business. I get that. It is also a wonderful professional calling and being both at the frontiers of science like the genome project as well as holding the hand of a patient who is asking about whether he should try one more desperate treatment is a remarkable privilege. Since I started my medical practice 34 years ago, the changes in both business orientation and in the technologies of medicine are breathtaking. All of that said, I remember when the doctor in my home town of Chadron, Nebraska, made house calls, drove a Buick and lived a few blocks away in a very modest house. Making himself rich was really not part of the equation, although he did well enough to send his kids to fine colleges and eventually build a nicer home.
The skewing of medical practice towards being a “small business” and away from a profession bothers me. Even though I agree with my sister who married a wonderful cardiologist and has a remarkable estate that “once doctors could actually DO something, it became a transaction”, it simply bothers me. My introduction to this real world started when we participated in the development of leuprolide, giving the first patients small but increasing doses, assessing saftety, and eventually designing the trials that led to FDA approval. When the price for a 3 month injection was announced, I was astonished. When a “me too” drug came out called Zoladex, I thought that the competition between pharmaceutical companies would drop prices. It didn’t. Instead, companies competed on behind the scenes pricing schemas that began to corrupt the doctors prescribing the drugs. Eventually (though not soon enough to save billions of dollars to our Medicare system), there was a whistle blower who got enough attention to stop the practice.
Now we find that business and profit have become the (maybe that should be THE) driving force in medical decision making. Urologists who used to make large sums of money off of the drug markup schemes with lupron, changed over to doing more orchiectomies as soon as the profits fell off. The study documenting this found the following: “The use of medical castration increased from 2001 to 2003, whereas, over the same period, surgical castration decreased. Total allowed charges for medical castration peaked in 2003 at $1.23 billion. After the enactment of the MMA, surgical castration rates increased, and medical castration decreased. Total allowed charges for medical castration in 2005 dropped 65% from the 2003 peak.” In other words when the profits for giving Lupron fell, surgeons started doing more surgery and stopped giving leuprolide shots in their offices.
Now the focus has shifted to seeing if more money can be made doing radiation therapy than surgery. Medicare has decreased the compensation for doing prostate surgery. Some large urology groups have formed and purchased their own radiation therapy equipment. .No problem with that if their practice of recommending surgery versus radiation for patients hasn’t changed. However the data for some of these groups suggests that is not the case. In a recent article from Bloomberg, the profit motive influences more and more urologist’s decision making. “one in five U.S. urologists add to their income by billing for the type of treatment in question, according to the journal Urology Times. Called intensity- modulated radiation therapy, or IMRT, it uses imaging software to focus multi-angled X-rays on tumors, aiming to deliver bigger doses with fewer side effects than prior technologies. This side business pays doctors up to $40,000 per patient from Medicare, or 645 times what a urologist gets for a standard office visit, and as much as 20 times what the federal insurance program pays a surgeon to remove a cancerous prostate gland, according to published studies. Reimbursement from private insurers for IMRT can be even higher, urologists say.” Dr. Cooperberg, of UCSF is quoted as follows: ““Doctors do what they’re paid to do” Cooperberg said. “If you tell them they can earn $2,000 for surgery or $37,000 for IMRT, what do you think will happen?”
The article goes on to state: “When urologists have a financial stake in IMRT, the portion of patients referred for it roughly triples within about two years, according to preliminary data presented at a radiation oncology conference in Miami Beach last year by Jean Mitchell, a health-care economist at Georgetown University.”
I find all of this very sad. I know dozens of urologists who are absolutely terrific and would never let profit influence their decisions on a treatment recommendation. I also know radiation oncologists who are incensed that urologists are invading their own profit making world, and of course there is no shortage of medical oncologists who “struggle to make ends meet” by giving the most expensive chemotherapy when they should be referring patients to compassionate hospice care. My point is that I don’t think very many medical student applicants start off with making money as their motive for going into medicine. I am disappointed in what my profession seems to do to some of them. I love medicine as a profession, not as a business.
5 responses to “Profiting from “YOUR” prostate”
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You are so on the point. As a retired ob- gyn, and a recepient of your sage counsel regarding prostate cancer, i couldn’t agree with you more. The practice of medicine should not be profit oriented but outcome oriented. An honest appraisal of a patient, and an honest treatment approach should be the goal, and reasonable compensation will accrue. That will not necessarily make a physician rich but his family will do ok and he will sleep well. Thank you for being the doctor you are. I am so glad to have met you.
Mike, Great comments. Making the case for single payer systems and some controls on what is paid for and at what rate. I am appalled at the cost of Lupron and Zometa since I pay a 20% co-pay. I too am now not so proud of my colleagues in medicine. As my daughter enters her first year of practice I am aware of the changing landscape from when you and I started.
8 years ago I started down the PCa nightmare road. At that time the decisions before me was led only by my Urologist, not any knowledge I had of this disease. Do I have a RP, seed implants, watchful waiting? I had no Idea what to do! I was only told about an Oncologist after all the Urologist recommended procedures failed and my PSA was rising. This brings me to adressing your comments. How would a PCa patient like myself know what direction to take and avoid the Dr.s who are profit oriented and not outcome oriented? I find cases of “Dr.s for Profit” while working with men in my PCa support group. We know what’s worked for us and what direction to take because of the hundreds of men that communicated their story with us. We do not represent our views as a Dr. but as experienced men who have been down the PCa road! I’m a good example of this. My knowledge of PCa procedures today might have saved the spread of the disease if I knew more 7 or 8 years ago. Example: The rediation I had 8 years ago (IMRT) of the prostate bed, (after RP) did’nt go far enough. Radiation of thr Iliac nodes in pelvic area very well could have stopped the progression. Where was the radiologist who knew this? Point made!
addressing your comments
Sad,but true. And it was always so. BUT when “Greed is good” became the norm, doctors also got infected. Financial ethics is a slippery slope when your neighbor moves to a new house.