Do doctors get rich from cancer?

Posted by on Sep 9, 2015 in Cancer Care, General Medicine | 8 comments

Do doctors get rich from cancer?

There are two, old, particularly nasty rumors, about cash and cancer. The first, which seems to be fading, is that scientists cured the disease long ago, but the pharmaceutical industry suppresses the cure so they can get rich selling worthless therapies. This never made sense to me, since the company or person that cures cancer will be rich beyond anyone’s wildest dreams. In addition, I have personally known several thousand cancer researchers and have seen their intensity and dedication; there is no chance even the smallest cancer cure “secret” is suppressed.

However, another ancient awful adage still seems to lurk, appearing every now and then to frighten, confuse and hurt my patients.

This week I met a gentleman with an aggressive cancer. After reviewing his records, taking his history, and doing an examination, I sat down to talk with him and his wife regarding choices. Before I could begin, his wife said, “I want you to know that we are not going to do chemotherapy, because our family doctor told us that the only reason oncologists give those poisons is to make money.”

While I have heard this piece of trash talk before, for some reason it hit me hard with this particular patient, whom I was working very hard to help. I understand that at times cancer doctors do order too much therapy. Moreover, I appreciate there are a few bad seeds. However, it is my experience that over treatment is not about profit, but because the doctor or patient has trouble letting go. Nonetheless, there continues to be real confusion regarding the motivation of the average doctor.

It is time for an honest conversation about money and malignancy. Could this family doctor be right? Is the average ethical oncologist looking at your CT scan images as a potential treasure trove of wealth? Do we go to our pharmacist and say, “Cheryl, mix me up 2 of those reds, 7 of those blues and 1 of that really expensive, but practically useless, golds, because that new Tesla is looking really good. Oh, and give them something to lose their hair, so we can sell those wigs we bought last year.”

Absolutely not. Can I be more emphatic? Never. Nada. Not at all.   It is not how doctors, who spend their life at cancer’s bedside, are wired. We see patients in pain, families in fear, the lives of our neighbors and fellow man threatened. We are trained and driven to attack disease. Beyond our oath to heal, we are deeply bound to each patient as fellow human beings. Even when we fail to connect at personal level, even when we are clumsy communicators, even when we seem distracted, we feel a responsibility to our patients and our profession and do not make decisions based on our own fiduciary benefit.

This is not to say that oncologists do not make money by providing chemotherapy. The average “margin,” the extra amount of dollars that chemotherapy in the outpatient setting is charged, is between 4 and 6%. That means that if the drug costs the cancer office $100 to buy, the office will receive in payment about $106 dollars. For expensive drugs, that can indeed add up to a lot of money. However, that “extra” is not profit. Where does that money go?

It pays for the secretary that schedules. The admin staff that precertifies. The pharm tech that orders. The pharmacist that designs and mixes. The LPN that takes vital signs, draws blood and “rooms” the patient. The lab assistant that runs the blood count. The nurse, usually bachelor trained with advanced certification in oncology, who educates and administers the IV medicine. The triage nurse that calls the next day and is available for support. The biller who deals with the health insurance company. The equipment. The IT. The heat. The water. Mortgage and lease. And the manager who runs the office.

As expensive as it is to run an oncology office, there is indeed a portion of that “margin” which is left behind. That goes to the oncologist. It pays the doctor for the tasks he or she performs, which are not billed with the regular office visit. Phone calls. Radiology and test review. Designing and monitoring treatment. Documentation. Training and critical conferences. $20,000 of malpractice insurance. Thus, in a well run office, a portion of his or her salary is from chemotherapy.

While many cancer practices have been under tremendous financial strain in the last 10 years, with hundreds going bankrupt and even more merging or being purchased by hospital systems, oncologists in successful practices, in general, have incomes in the top 25% of physicians (US average $269,000/yr). A portion of this pay is indeed from chemotherapy. A large part is from office and hospital visits, with many doctors seeing 30-40 patients a day in the office and more in the hospital. In the end, the medical complexity of practicing cancer medicine, as well as the real financial distance between what the doctor orders and what he is paid, make choosing a treatment for remuneration not only immoral, but unlikely.

I was able to convince this patient and his wife that any suggestions I make regarding treatment, are about giving him the best chance to live, not about helping me live well. I explained the choices for care, and each benefit and risk, which I supported not only with 30 years of experience, the latest of research and expert opinion, but by connecting at a personal level. As always, I promised that I would be there for them, support them, walk the path with them, no matter what the cost.

 

 

8 Comments

  1. Dr. Salwitz, I learn so much from you, and I quote you often. Thank you for making time to write.

    PS I sure hope that besides everything else you do, you are directly teaching future physicians. They need to walk the halls and breathe the same air as you.

  2. Hang out on support groups where that allow conversations about “natural” and “alternative” treatments(instead of sticking only to treatments that have some science behind them) and you will find that the big pharma is suppressing the cure for cancer so they will get rich is alive and well. Never mind that the woo these snake oil salesmen sell is very expensive so they are also getting rich. The chemo is a poison; doctors get rich from chemo is the first cousin to this.

    Reason tends not to work with people who have bought into woo and snake oil. Telling them if there was a “natural” cure for cancer out there that it wouldn’t be suppressed; that instead big bad pharma would figure out what active ingredient is the one responsible, purify it, patent it and then get rich doesn’t usually make a dent in their thinking.

    We do not teach enough science in K-12. I have given up arguing with these folks. I’d write (online) things like, if you believe that a lumpectomy and radiation is as good as a mastectomy (I have had both breast cancer on both sides and one of the non-curable non-hodgkin’s lymphomas); that a sentinel node biopsy is as good as taking them all out, both of those are based in science, then why do you not believe that X chemo is better than Y treatment when the results come from science? Science is like gravity – it works all the time, not just when you want it to.

    If real doctors knew how to market themselves and were as persuasive as snake oil salespeople that might make somewhat of a dent. My personal opinion, after observing this idiocy from the patient point of view on support groups is that what this is really about is fear – of cancer, of dying of it, of side effects of chemo, of losing one’s hair, and about hope, etc. And the snake oil salespeople tap into that fear and then reassure the patient that they have the solution that will work (no if, ands and buts about it), avoid all the things they are afraid of, any medical professional who disagrees is part of the conspiracy, blah blah blah. And so the snake oil salespeople tap into that fear and exploit it for all it is worth.

    Their testimonial pages on their websites are all about success when the medical profession gave up on the patient. They do not list their failures or their success rate. There is no evidence that anyone giving one of these so called testimonials was ever there – give me a couple of hours and I can pull photos off the web, photoshop the background to make them all look like they were taken elsewhere, and write some nice testimonials under that. Of course when cancer patients and their families have drunk the kool-aid and believe the snake oil salespeople no one can dissuade them of anything. The snake oil salespeople have also give them the answers to critics.

    The medical profession is honest about the odds, the side effects, the issues and problems. How do you stand a chance against this kind of thing?

  3. Some accusations like that have been in print long past, but remembered. Thank you for bringing truth.

  4. What I find disturbing is that the family doctor was pretty much trying to stop his patient from getting treatment. It’s for the patient to decide about treatment. I actually see a different problem that’s more wide spread in the health industry.

    Those with little education, experience, etc. thinking that they know more than the truely qualified. .I had a substitute physical therapist refuse to do PT on me because I have cancer in remission. She told me that she wouldn’t follow directions, because she was cancer certified. Who did the certification? Apollo, ITT or other quickie for profit advertised on TV online sites? They’d certify my coonhounds.

    Then there seems to be a group of people that probably can’t hold down a job or don’t get promoted. They flock to cancer certification, to work in the new cancer support center that have dietitians, yoga instructors, different exercise equipment coaches, PTs, OTs, speech therapists, weight lifting coaches, and on and on. Many of these either go online at real university-some spend several months on these courses, others can be a 6 hour course at Continuing Ed.

    I won’t have anything to do with my HMO Cancer healthPlex- we don’t have centers anymore for several reasons. The yoga instructors make fun of people that are more comfortable praying instead of meditating. They put down weight lifting, but weight lifting is needed for lymphedemia. I knew more exercises than the weight lifters. They were going around to promote the healthplex. The last day they said that they’d give us an example of an intake assesessment. Stand-sit-stand-sit- do 45 in 45 seconds, and we were told to do them as fast as possible. I watched people with one lung, stomach surgery do a few, and they were told to stop. So, I did it too. They didn’t stop me at 6, which is supposed to be done. They watch for cognitive function-do you understand, can you follow directions, balance, vigor, ability, etc. I did over a dozen-2 days later I was dragging my leg, an old hip muscle injury was re-injured.

    Then I had a PCP that wanted me to loose weight-girth- I’m short-my waist went from 32″ to 40″ from radiation bloat in the 3rd week of treatment. Then my oncologists wanted me to fatten up before treatment-then they told me not to lose weight after treatment. This PCP decided that he knew more about cancer than the oncologists and actually confronted them. He lost-big time.

    Then most knowledge is based on breast cancer. I have head cancer. Then 2 weeks ago, some tech at the opthamologist slamed that heavy thing right on my nose. Part of my nose was removed. My HMO had a great surgeon fix my face. I screamed and jumped, and she talked to like I have Alzheimers. When the doctor came in, I told her that I was OK. i figured that I ranted the tech more than enough. It hurt, but what do you expect if your nose is hit? About 8 hours later I was at Urgent Care. for the pain in the surgery site, the other side was OK. I’m seeing my ENT next week, because it’s still hurting and feels swollen inside.

    I told the regular PT clinic to put CANCER FACE on the front of my chart with a sharpie, so if someone doesn’t want to care for me, she can say so. Maybe I can stay home instead of being publically humiliated. I told the eye doctor’s head nurse to write CANCER NOSE, and lecture the techs from TV land to be gentle. I told her that if that happens again, I will complain and change doctors.

    Anybody that suggests that I go to the healthplex, I tell them that I was put in PT by them, and I was dragging my leg. I will not go there because, I don’t want to end up in a wheelchair.

    This doctor spouting how cancer treatment is a rip-off is just another example of how unqualified people are impeding cancer treatment, and impediment comes in many forms from many levels. There are people that are profiting from cancer, very few are the oncologists.

    Thank you for letting me talk about this problem.

  5. So what percentage, do you suppose, of the entire adult population of just this country (or all those of the age having the ability to understand wealth) would not think that someone earning $269,000/year (let’s even round it down to $250,000/year) is not rich? Not billionaire rich but easily millionaire rich (depending of course on lifestyle choices and financial savvy).

    I agree that the “average ethical oncologist” does not do many of the things you say solely to bolster profits but there is a profit motivation and profit incentive in all of it. And, not all oncologists are either average or ethical, are they? There are even some who are found to be practicing without a license. Are they doing this for humanitarian reasons or do you suppose it might be for the (good) money? Some of them (not a lot) are doing it for the money AND prestige of writing papers and use some patients as lab experiments. How else would you explain how an oncologist can say to a patient, “just think how much I’ll learn from your death.”

    You cannot extract one element (chemotherapy) from all that you do and claim that you have such a tight margin that you barely squeak by. Because then you turn around and say (about your income) that “a large part is from office and hospital visits.” Is this not income generated from the treatment of cancer, as well?

    And what of your past writings/inferences that some oncologists (and/or physicians in general) do some things because it is “standard of care” which means primarily it will be reimbursed. What of your past writings/inferences where some oncologists (and/or physicians in general) do more tests, etc. than are truly needed just to cover themselves from malpractice suits? Is it inconceivable that some oncologists may create a more potent chemo cocktail just to be certain that they cannot be accused of under treatment of the cancer? Just like the lawsuits regarding under treatment of pain.

    You don’t make any claims as to how the oncology business operates…is it truly independent and pays all of its bills solely? Is it part of a hospital and pays a percentage of total revenue or an amount based upon square footage of occupied facility space? Is it part of a conglomerate that has yet another way of allocating costs among all parties?

    I understand that you are writing about the “life” that negative stories can have. But to say, “Absolutely not. Can I be more emphatic? Never. Nada. Not at all.” may be true for some, but may not be true for most. As an overall statement it is not true. To then substantiate it with a cherry-picked single item (from the whole billing process) is somewhat disingenuous.

    What’s even worse is that some oncologists (and some physicians in general) in order to sound cute or more approachable joke with patients by saying that they’re doing some test or treatment because they have their eye on a boat or need something to finance their annual trip to the Bahamas. Sure, it’s funny and personable but it also helps to propagate the myths and ends up making physicians their own worst enemy.

    I agree with your overall points but your attempt at a supporting financial explanation is not working. Of course, all doctors do things to make money. I would say that the vast majority of people in this country would say that most doctors do quite well for themselves, monetarily, in treating cancer. How many would claim that doctors get “rich” would depend on each person’s definition of “rich.”

    But not all doctors do the same things that other doctors do with money or personal gain, of any type, as their primary motivation. This is one of the traits that differentiates a good doctor from a not so good doctor. How a doctor reacts to a patient’s comment such as you experienced also differentiates a good doctor from a not so good doctor. A financial explanation is not the best choice. It answers the concern no better than if the doctor were to offer the patient his/her bank statements, last three years of tax returns and showed them that he/she only has six bucks left in their wallet to last until their next paycheck. No one buys the “I’m just a poor cancer doctor” explanation.

    The best, most appropriate thing for a doctor to do is to show the patient everything necessary to support the (doctor’s) contention that this is the best and most likely successful treatment for that patient at that time. This is much more difficult than a 4 to 6% markup on product. The former is exactly what you did and you should be commended for it.

  6. Some say making money while some say losing money. Here are some interesting and differing perspectives on physician billing and reimbursement issues. Likely both are correct depending upon which drug is being talked about.

    From last year on KevinMD:

    http://www.kevinmd.com/blog/2014/08/oncologist-pay-chemotherapy-buy-bill-needs-stop.html

    From the year before on ASCO (American Society of Clinical Oncologists):

    http://www.asco.org/advocacy/asco-action-brief-physician-administered-drugs-%E2%80%94-evolution-buy-bill

    From the year before that on NYtimes book review/interview (with plenty of blame to go around for all involved in all aspects of care, including patients):

    http://well.blogs.nytimes.com/2012/04/20/how-doctors-and-patients-do-harm/?_r=0

    I was particularly impressed with the author’s (from last link above) conclusion that “no incident of failure in American medicine should be dismissed as an aberration” and that “Failure is the system.” And his blaming patients who believe that more of everything equates to better care.

    There is also (from ABIM Foundation – American Board of Internal Medicine Foundation):

    http://www.choosingwisely.org/doctor-patient-lists/

    which details treatments that may be of importance for discussion between doctor and patient.

  7. I read this article here ” Legalize medical marijuana? See how a decision can affect this cancer patient.” and said OH MY GOD I FINALY FOUND AN OCOLOGIST HWO IS NOT ALL ABOUT CHEMO AND RADIATION AND OFFCOURSE PROFIT- MONEY FROM BIG PHARMA!!! Nope I was wrong I know that now from this post here. RECOMEND this documentary from Dr. Sanjay Gupta at CNN called WEED and especialy at minute 35:25 – https://m.youtube.com/results?layout=mobile&q=dr+sanjay+gupta+weed&sm=1&tsp=1&utcoffset=60

  8. I really like that you wrote this. I had someone say to me when I told them that a neurologist wanted my husband to have an MRI to check on his brain tumor, Oh, he must need a new car, or something to that effect. It really bothered me because I coukdn’t imagine a doctor doing something like that just for the money. I have lost sone faith in doctors since then. I truly believe my faith should be in God and not men, but I also believe that people have to believe that doctors want to help them heal and not harm them. My husband just passed away in October in in-patient hospice. He had an astrocytoma grade II ( at least I think..the doctors didn’t seem to be sure it was grade II. Anyway, it was hard. I really miss him very much and I wish he could have talked the last week so I would have known what he was thinking and feeling.

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