In the June 10 issue, Joe Simone as usual enlightened us with one of his beautiful writings. Although QOPI was the intent of the presentation he made at ASCO [the subject of this column], he also gave us an introduction to quality cancer care in community oncology practices and compared that with pediatric oncology, which is predominantly hospital based.
I agree that American pediatric oncologists have done a remarkable job in advancing the treatment of childhood cancer. I am not sure, however, that this should be credited to the presumed lack of conflict of interest. I think it has more to do with a culture that evolved in the pediatric oncology world.
The assumption that hospital-based physicians are immune to potential conflict of interest is probably an overstatement. The cost of cancer care in the hospital setting has been shown over the last two decades to be much higher than cancer care provided in the community. All you need to do is ask the insurance executives of your choice, who will tell you that hospital-based cancer care exceeds that delivered through the community oncologists and markedly so.
Physicians employed by hospitals and academic centers are under constant subtle pressure to overutilize through case managers, patient navigators, and social workers. Productivity incentives are built in to most academic and hospital-based appointments. Can we argue that such arrangements are devoid of conflict of interest?
The bottom line, the sad fact, is that conflicts of interest are so rampant that you would wonder who actually is the best patient advocate. Hospitals advertise that, but those who open their eyes know better—hospitals are more interested in profit and bonuses to their executives than patient care.
The assumption that physicians who are employed by hospitals are or would be free of conflict of interest is not well founded. In fact, a case can be made for the contrary. If “good medicine is cheaper medicine,” which I think it is, it would be very hard to agree on Joe's contentions that quality care delivered through hospital-based oncologists is superior to that delivered through community-based oncology.
NASH GABRAIL, MD
Gabrail Cancer Center
Reply from Dr. Simone:
Many thanks for your note. We will never have a controlled study to prove that being hospital-based was the reason for the success of pediatric oncology. The fact is that greater sensitivity of pediatric tumors to chemotherapy is the key reason.
I agree that conflicts tempt us everywhere. I do believe the opportunities for conflict of interest are far fewer for pediatric oncologists than for adult oncologists. It is true that data shows that care may cost more in some academic institutions, particularly those on the East Coast. However, to say that cheaper therapy is better therapy is a gross oversimplification; I am sure you would agree.
I am also sure that you would agree that at the peak of medical oncology reimbursement a number of years ago, studies showed that 65% or more of all income in those practices came from reselling and administering chemotherapy (lousy reimbursement for seeing patients bears much responsibility). That is one conflict of interest that does not tempt pediatric oncologists because it is not available; it is also not available to most hospital-based medical oncology practices.
Of course, academic oncologists have their own conflict-ridden bête noir; it is being on speaker panels for Pharma or serving as “consultants.” I have been told that the common standard today for such speakers is that they must use slides prepared by the pharmaceutical company.
The bottom line is that we cannot eliminate all the potential for conflicts of interest, but diligence will help us stay out of that arena.