In my last column (April 25 issue), I cited studies that described the evolution of medical specialists from acting as “single agents” (for the patient), to “double agents” (for patient and payer), and now to “free agents” (for themselves). I called the free agents “econo-docs,” for whom economics comes first and the doc part last.
And now I ask: Are we oncologists like the interventional cardiologists and orthopedists cited in the articles?
It is impossible to deny that there are some of us in oncology who behave as if the patient serves principally as a source of revenue and whose practices are focused inordinately, and sometimes obscenely, on the business of medicine. I have spoken with numerous oncologists who can provide examples of (other) oncologists who fit the profile of the “econo-docs.”
Econo-docs engage in behavior that is unprofessional at best and mired in unethical conflicts of interest at worst.
A few examples of such behavior follow:
▪ Prescribing chemotherapy that is futile (“churning”).
▪ Prescribing expensive agents, like erythropoietin, without justification based on established guidelines.
▪ Prescribing chemotherapy that the oncologist sells to the patient at an exorbitant markup.
▪ Ordering outpatients to receive costly intravenous hydration that is not indicated.
▪ Using software programs to choose among drugs not by relative efficacy and safety, but by highest profit margin.
▪ Preferentially referring patients to other specialty services in which they personally hold equity positions that are hidden from the patient and public—e.g., radiation oncology or diagnostic imaging facilities.
Other examples include responding to the pending decline in chemotherapy reimbursement by sending to their patients frightening letters that threaten the use of inferior or more toxic therapy, or indicating to their Medicare patients that they may no longer be cared for (as described in an article in the New York Times on 3/11/04 and an editorial, “Cancer Scare Tactics,” on 3/22/04).
An informal survey of community medical oncology practices revealed that top incomes in a practice can exceed $1,000,000, particularly in large practices in smaller metropolitan areas.
To be sure, HMOs, Medicare, and medical insurance companies have created a perverse system of reimbursement. The system values an appendectomy more than spending hours establishing and telling a cancer patient the diagnosis and prognosis, laying out the treatment options, talking to the family, and repeating information that the often stunned and distraught patient cannot remember from one visit to the next.
The system has also rewarded oncologists far more handsomely for the purchase and resale of chemotherapy than for face-to-face care of the patient.
Yes, the system's incentives are terribly warped. But with few exceptions, the outcry of the oncology community at the unjust reimbursement schedule came only after the lucrative chemotherapy business was threatened.
Just Minor Aberrations?
Should we respond that these econo-docs make up a minority of cancer care-givers and, therefore, should not concern us? Should we ignore them as minor aberrations that one is likely to find in any profession? Or tolerate them as overzealous business types who occasionally step over the line of ethical propriety? “Boys will be boys?”
Well, let me test the reader's response with related questions:
▪ Is the reader outraged at rapacious business leaders' theft of billions of dollars from ordinary people, while lying and cheating to hide their crimes?
▪ That CEO/chairmen vote themselves almost unimaginably rich compensation packages as their companies consistently lose value?
▪ That cozy complicity in these shenanigans is practiced by certified public accountants?
I am, and I hope the reader is. One might argue that these professionals committed more serious breaches than the econo-docs and that some were engaged in criminal activity.
But the concern here is not for legality, but the much higher standard of professional ethics.
We Are Held to Higher Standards
As professionals who are entrusted with the care of the sick and who take an oath of ethical behavior, we are held to much higher standards because we care for people at very vulnerable and often dangerous periods of their lives.
The behavior of econo-docs has exposed major cracks in professional ethical norms that include actual or potential conflicts of interest.
Most of all, by taking advantage of vulnerable patients, econo-docs betray the public trust—that is what should concern us most of all.
It is true that there are some scoundrels in every profession. But the bigger worry is that our silent tolerance, and sometimes admiration, of the econo-docs' entrepreneurial activities may insidiously encourage some of the large majority to cross the line and engage in practices devised primarily for economic gain.
The irony is that econo-docs most likely will find a way to prosper under the Medicare Modernization Act of 2003; it is the more non-entrepreneurial docs who are likely to suffer most and even be forced out of business.
While an ethical profession may be embarrassed by the transgressions of the few, the quiet acquiescence, approval, and participation of the many ordinary, basically decent docs eventually destroy its professional fabric.
Just because our patients like us and trust us does not necessarily mean we give high-quality care that is free of economic conflicts of interest.
It is the professional responsibility of each of us and of our leaders to be vigilant and take steps to assure ourselves that both, in fact, are so.