Lab Soft News

Solid Advice for Older Men Regarding PSA Screening for Prostate Cancer

PSA screening for prostate cancer, like cats, seems to have nine lives. Researchers and clinicians are always bemoaning the shortcomings of this test but it won't go away because there are no better substitutes and because of its familiarity. Moreover, new research continues to demonstrate new uses for the test. A recent article is a case in point, indicating that the PSA level of 60-year-old-men has value in predicting the likelihood of dying from cancer of the prostate during the patient's lifetime (see: Simplifying the Decision for a Prostate Screening). Below is an excerpt from it:

...[H]ow does a man decide whether to get P.S.A. screening or not?  Finally, some new research offers simple, practical advice — at least for men 60 and older. Researchers at Memorial Sloan-Kettering Cancer Center in New York and Lund University in Sweden have found that a man’s P.S.A. score at the age of 60 can strongly predict his lifetime risk of dying of prostate cancer, according to a new report in the British medical journal BMJ. The findings also suggest that at least half of men who are now screened after age 60 don’t need to be, the study authors said....The researchers found that having had a P.S.A. score of 2.0 or higher at the age of 60 was highly predictive of developing advanced prostate cancer, or dying of the disease, within the next 25 years. About one in four men will have a P.S.A. score of 2.0 or higher at the age of 60, and most of them will not develop prostate cancer....But the score does put them in a higher-risk group of men who have more to gain from regular screening, [an author] concluded. The higher the score at age 60, the greater the long-term risk of dying from prostate cancer.... Men with a score of 2.0 or higher at age 60 were 26 times more likely to eventually die of the disease than 60-year-old men with scores below 1.0. Still, the absolute risks for men with elevated scores were lower than might be expected. A 60-year-old man with a P.S.A. score just over 2.0 had an individual risk of dying from prostate cancer during the next 25 years of about 6 percent....A 60-year-old man with a P.S.A. score of 5 had about a 17 percent risk....Men with a P.S.A. score of 1.0 or lower at age 60 had a very low individual risk of death from prostate cancer over the next 25 years, the study found: just 0.2 percent. The advice is less clear for men with scores between 1.0 and 2.0 at the age of 60. They still have a very low individual risk of dying from prostate cancer, judging from the new data. The long-term risk of dying from prostate cancer ranged from about 1 percent to 3 percent for these men, and the decision to screen may depend on their personal views and family histories....

I really have little more to add to this discussion other than to quickly summarize the findings. If you are a male who is 60 years old and your PSA is 2.0 or higher, you need to be very vigilant and continue to be tested for PSA and also undergo periodic physical exams. If you are the same age and your PSA is 1.0 or lower, you seem to be out of the woods, at least as far as cancer of the prostate is concerned. Return to this news article and the original medical article from which it was derived if you have additional questions.

A Lottery to Improve Patient Adherence to Warfarin Therapy

The idea that health insurance companies should pay or reward their customers to lead healthier lives poses a set of moral conundrums. Those opposed to such a policy correctly state that a health insurance company should not need to pay individuals to improve their own health. Are not such benefits so appealing in and of themselves that no additional incentives are required? Supporters of such plans will often respond in the following way: Use whatever means that work because the end justifies the means in terms of cost savings and the pursuit of wellness. Here is an excerpt from an article on this topic as it relates to medication compliance (see: Insurers Try Incentives to Improve Medication Adherence):

The poor compliance not only affects quality—nonadherent patients have higher hospitalization and mortality rates, according to research—but it also makes healthcare more expensive. The overall cost of poor adherence, measured in otherwise avoidable medical spending, may account for as much as $290 billion per year, or 13% of total healthcare expenditures, according to an estimate from the New England Healthcare Institute. Insurers have yet to find the right "spoonful of sugar" to cut some of these alarming statistics, but many are experimenting with new incentives and getting creative in their approaches. For instance, Aetna Inc. is funding several pilot projects that test how giving medications to patients for free, rewarding patients for lowering blood pressure, and even giving financial incentives for compliance can improve adherence....The latter approach has been one of the most successful so far. Funded in part by Aetna, a group of researchers from the University of Pennsylvania recently set up a daily lottery with potential financial rewards for patients who had been prescribed warfarin (see: Testing Strategies to Improving Warfarin Adherence). Each day when patients remembered to take their medicine, they had a one-in-five chance of winning $10, or a one-in-100 chance of winning $100. When they missed their medicine, they could still see what they would have won, but didn't, that day.

I personally think that the idea of enrolling patients in a lottery to improve adherence to drug therapy is a brilliant idea. Let's face it, different patients and healthcare consumers respond to different types of incentives. One of the strongest predictors of healthy habits and a long life is the amount of education achieved. This, in turn, correlates strongly with family income, role models, and the quality of public education (see: Family, culture affect whether intelligence leads to education). For many people, the deck is stacked against them in terms of their attitudes toward higher education as well as improving their health status. If a lottery underwritten by small amount of prize money can serve as an incentive for people to take their meds or follow a therapeutic regimen, I support the idea. Note that I say here "a small amount of money." In such a case, the program costs are relatively trivial. They can serve as an incentive but not a false get-rich-quick scheme.

Genomic Testing for a Predispositon to Cancer: Individual Rights of Consumers

One of the most interesting and challenging issues in the health insurance world these days is the determination of which members covered by a plan should receive genomic testing for a predisposition to cancer. Not only are such tests frequently expensive but they can also lead to downstream costs, particularly if a decision is made to pursue prophylactic surgery. In such cases, "normal" organs are being removed. The most obvious example of this scenario is BRCA1 and BRCA2 testing. A recent article discussed a study funded by Aetna about this topic (see: Who Gets Genetic Testing for Cancer?). Below is an excerpt from it:

Aetna is examining data from 13,000 of its members to figure out if patients who should be getting breast-and-ovarian cancer screening tests are in fact being offered them. Such tests, which cost up to $3,000 a pop, screen for genetic defects that put some women at high risk of these cancers. A positive result means that extra precautions should be taken to make sure a cancer is caught at its earliest stages. But Aetna says there are questions about whether women most at risk are getting the tests, and whether there are socioeconomic and racial disparities in their use. There’s some evidence, like this study by the Robert Wood Johnson Foundation, that suggests that differences in use exist. The company’s two-year study, described here, could help it identify members most likely to be helped by the costly test and reduce spending on testing for women who might not need it. “There is valid concern that some women are receiving this test unnecessarily, while others, particularly among racial and ethnic minorities, as well as poorer women, should be receiving these critical tests and are not,” said Anne Beal, president of the Aetna Foundation, an independent charitable arm of the insurer. “This study may validate the need for specific strategies to eliminate barriers to these tests –- whether they are knowledge-based, culturally-based, or access-based –- and help improve the health outcomes among high-risk poor or minority women.” 

Although the over-utilization of lab tests has received the most attention over the past decades, more attention is now being paid to the under-utilization of lab tests. I very much like the phrase used in the article above: the need for specific strategies to eliminate knowledge-based, culturally-based, and access-based barriers to lab testing. In my opinion, we know the least about the cultural factors that lead to both over and under-utilization of lab tests. Here's an interesting quote from a recent article about "omics" testing (see: Challenges of the ‘‘Omics’’ Future and Pathology Informatics Systems):

...[T]echnology often brings about unexpected consequences; the same applies to genomic technology and proteomics analysis. The examination of genetic sequences carries significant bioethical, social, and cultural implications. From a bioethical standpoint, patients will lose individual power to decide whether they want to know their genomic structures. The analysis of human genome through laboratory testing has the potential to create data warehousing and data mining in the discovery of new knowledge. From a utilitarian point of view, this action is justifiable. It is, however, important to realize that the individual right of consumers is breached in the process of knowledge discovery. From the socio-cultural standpoint, the availability of genomic analysis might reveal some important yet unacceptable ‘‘facts.’’

I want to return at some later time to the question of medical knowledge discovery versus the individual rights of healthcare consumers. Right now, most of the weight is on the former because of the general admiration in society for scientific discovery.

Blogs Becoming Increasingly Popular and Blending with Other Media

It's been about three years since I posted my last note about blogs and blogging. I view myself as a professional blogger (see: Professional Blogs as Publication Vehicles for Physicians in Academic Clinical Tracks; Professional Blogs as Meta Information Resources). By this I mean someone trained in a particular industry or discipline, pathology and the clinical labs in my case, who then focuses on news and events in that industry, A recent article raised some interesting points about blogs and I provide an excerpt from it below (see: Blogging is Alive and Well, Says Report):

While blogging was still a major topic of discussion just a few years ago, things have been rather quiet around it in recent times. Even in the so-called blogosphere, we don't talk a lot about the actual activity of blogging anymore these days. [H]owever, blogging is still alive and well. Today, half of all Internet users read blogs and while blogging itself remains somewhat of a niche activity, about 12% of U.S. Internet users update a blog at least once per month....60% of U.S. Internet users will be reading blogs by 2014....[T]his upward trend will likely continue, but, [according to an expert], over time, blogs will continue to become indistinguishable from other media channels. Indeed, we have to wonder how many blog readers aren't even aware that they are reading blogs. Since the early days of blogging, the word "blog" has meant different things to different people. After all, it can refer to both a personal diary and a serious media publication in reverse chronological order. One actually has to wonder whether the 50% of today's Internet users who say they don't read blogs simply aren't aware of the fact that they are reading them.

Below are two tables copied from this article demonstrating the growth of blogging:

There is no question in my mind that the vast majority of people on the web read blogs but are not necessarily aware of this fact. I am sure that the percentage of them far exceeds the 50% estimated above. To restate the obvious, blogging is becoming "indistinguishable from other media channels." In the case of pathology and the clinical labs, a prime example of one of the most important media channels is CAP Today. It's written by professional journalists and published in electronic and hardcopy form by one of our major professional societies. The September issue can be viewed in digital format. Although this blog has no formal connection to CAP Today, I have always written it as though it were a column in the publication designed to comment on industry news for lab professionals.

The key question in my mind about the future of blogs and blogging is now the following: if the term blog is losing its meaning and many people don't even know that they are reading a blog on-line, has the term now become devoid of meaning? If so, how will we refer to today's blogs in the future? Perhaps we need some new acronym that captures the idea of web-based news and commentary. We also need new ways to access all breaking news in the lab industry. One of my favorite apps on the iPad is the Flipboard, that allows you to select publications like The Economist, Wired, or Twitter and browse their stories like reading a magazine. In the latter case, you are only shown the Tweets posted by people you are following and thus choose the content you are viewing. We need to develop a "clinical lab and pathology e-magazine" for Flipboard that provides an overview of breaking news in the industry.

Assessing the True Cost of Serving as a Beta Test Site for the Beaker LIS

I have been trying to keep abreast of the news relating to the Beaker LIS, given that Epic is closing most contracts in high-end hospitals and their labs are sure to get caught up in this process (see: Introducing the Epic Laboratory Information System (LIS); It's Called Beaker; An Update on Epic's LIS, Called Beaker, from HIStalk; More Information about Epic's Beaker LIS and Its Sibling). I have been told that Beaker is now live in a a number of physician offices labs and a few hospitals with the 500-bed Sanford Health in Sioux Falls, SD, as one of the major show sites. Two hospital systems are now considering the installation of Beaker, Allina and OHSU. The latter, previously running GE's Ultra LIS, is apparently seeking a replacement for this system with some degree of urgency.

Epic maintains on its own web site that the Beaker LIS supports best-of-breed functionality. My personal definition for a best-of-breed LIS is that it will meet or outperform most or all of the LISs in the market across a wide array of functions. This is a tall order given that the well-known and established LISs have been installed in hundreds of large hospitals and have have been in operation for decades. It may be the case that Beaker actually meets this definition and will serve both Allina and OHSU well but let me express here some degree of skepticism about this claim for a product that is currently running in only a small number of sites.

In fact, I would suggest that any lab that installs and runs Beaker qualifies as a beta test site for the product, defined in the following way: Second-phase test of a new computer system or program in a live operating environment. Beta testing helps to identify flaws in the system prior to a full-scale introduction. There is nothing wrong with being a beta test site. All of the LISs currently in the market were in a beta phase earlier in their development cycle. However, serving as an LIS beta tester places intense pressure on lab resources for two reasons: (1) veteran lab personnel spend much of their time communicating with the software developers, discussing how to correct software problems and increase system functionality; and (2) extra personnel then need to be added to the lab work force in order to compensate for the work not being accomplished by the newly installed and immature LIS. I would estimate that lab productivity decreases by at least 30% in a beta test mode and this situation often persists for two or more years depending on the rate of progress.

It would be instructive for Allina and OHSU to know before they sign up as Beaker beta testers whether there are any major functionality gaps in Beaker, how lab operations will be affected by them, and how many new FTEs they will need to hire. This can be accomplished relatively easily. Most high-quality LIS RFPs (requests for proposals) contain a list of statements, categorized by function (e.g., order-entry, result-reporting, quality control, billing), and stating the various tasks that the new LIS will be expected to perform (see: More Ideas about Developing and Refining an RFP). Competing vendors respond in writing to each of these statements, documenting for each whether the particular task can be accomplished or not by their system. These written responses to the RFP become part of any eventual contract and can be used legally to hold the vendor to these terms. The lab leadership at Allina and OHSU merely needs to borrow an RFP from colleagues in other labs and ask Epic to respond to a detailed list of the LIS functions that will be required from Beaker.

I am acutely aware of the irony of requesting a response to functionality requirements for a system (i.e. Epic) that has already been purchased by a hospital. I suspect that the upcoming availability of an acceptable LIS was included in the total Epic purchase price with the LIS, in a sense, being obtained for nothing. Unfortunately, it's the true cost of installing a beta or open-source LIS that prompted the saying: I can't afford a free system. However, I beg forbearance on this issue because I didn't coin the phrase "enterprise solution" nor do I personally believe that it's a viable approach to hospital computing when taken as a whole. The intense specialization of the various diagnostic units such as lab and radiology militates against it. I will therefore make no pretense at defending the idea.

Update on the Web Search Wars; Yahoo Influence Diminished

For the first few years of the publication of this blog, I observed that Yahoo was usually the most popular search engine used by my readers. This surprised me because I always personally used Google for my searches as did not most my close friends and colleagues. I recently checked the statistics of the incoming traffic to Lab Soft News by search engine. I discovered that the ratio of Google-initiated searches to those of Bing is now a whopping 14:1 and that Yahoo searches have almost disappeared. I see perhaps 50 of them per day. I decided to do some snooping around and found a recent article on this topic (see: Bing's popularity shows impressive growth. But it's still way behind Google). Below is an excerpt form it:

Our well-heeled colleagues over at Nielsen reported that Bing's US market share grew to 13.6 per cent as of July 2010. While that figure doesn't sound all that impressive, especially next to Google's 64.2 per cent, it does represent a 51 per cent increase for Microsoft's search engine over the previous year. In comparison, Google's share fell by one per cent over the same 12 month period. Nielsen's figures put Bing in third place just behind Yahoo, though...Yahoo's US search operations were being powered by Bing, meaning it is almost certainly became Google's chief rival. Microsoft will also take solace from the fact that when the number of searches was taken into account its growth outpaced all its rivals, recording a 28 per cent increase....Given the impressive growth of Bing, it will be interesting to see how much Microsoft will gain from taking over Yahoo's search operations. The problem for the outfit is that achieving 50 per cent growth is relatively easy when your market share is low, so the big question is whether Bing can continue to grow and start to really challenge Google.

So Yahoo is disappearing from the web search business and Microsoft/Bing is the only rival in sight for Google. Microsoft has its work cut out for it if it wants to overtake Google. I don't know about you, but I am delighted with Google's recently released Instant product that shows search results real-time as you type. Benefits of this product are described by Google in the following way:

• Faster Searches: By predicting your search and showing results before you finish typing, Google Instant can save 2-5 seconds per search.
• Smarter Predictions: Even when you don’t know exactly what you’re looking for, predictions help guide your search. The top prediction is shown in grey text directly in the search box, so you can stop typing as soon as you see what you need.
• Instant Results: Start typing and results appear right before your eyes. Until now, you had to type a full search term, hit return, and hope for the right results. Now results appear instantly as you type, helping you see where you’re headed, every step of the way.

The UnitedHealthcare Business Model; Comparison with Roche and Siemens

The New York Times of September 16, 2010, carried a full page ad sponsored by UnitedHealthcare. I have posted a number of previous notes about this large company, some of which have not been very flattering. Emblazoned across the midriff of a running woman in the ad is the following slogan: Knowledge in numbers, Strength in numbers, Humanity in numbers, Comfort in numbers, Health in numbers. Get it -- the business model for UnitedHealthcare must have something to do with numbers, as in the management of administrative, financial, and clinical data in healthcare. The company's web site is HealthinNumbers. I am not exactly sure with whom this motto resonates, but let's move on. About a month ago, Mr. HIStalk opined about UnitedHealthcare from an investor's perspective (see: Healthcare IT from the Investor’s Chair 8/23/10). Here is an excerpt from his long piece:

Ingenix, as all likely know by now, is the wholly-owned IT subsidiary of UnitedHealth Group, one of the largest publicly traded managed care companies. Mr. HIStalk himself recently posted a list of its recent buys. The first thing that’s noteworthy to me is its dramatic movement from only managed care-focused companies — such as Symmetry, Claredi, or AIM — towards first the hospital business office (CareMedic, Executive Health Resources) and then towards the clinical side of the healthcare system (Picis and, most recently, Axolotl). When Ingenix tried to buy managed care claims system vendor TriZetto a few years ago, it was going to make the questionable bet that its competitors would purchase their core systems from them. A stretch, but one with precedent. Now it’s betting that hospitals and physicians will not only pay real money to the Great Satan of Managed Care, but that they’ll entrust their clinical data to it as well.

In my note yesterday, I described the business models of both Roche and Siemens, each with critical links to diagnostics (see: Evidence that Roche Is Distancing Itself from the Traditional Pharma Business Model). Using abbreviated phrases, the first can be described as companion diagnostics & personalized medicine. The second can be referred to as integrated diagnostics. I now cite a third healthcare business model that I see emerging, which is that of UnitedHealthcare. I would describe this third model as information & health insurance. From the perspective of pathology, there is a very real difference between these first two models and that of UnitedHealthcare. In my opinion, Roche and Siemens view pathologists, radiologists, and lab medicine physicians as customers and key allies. They are the purchasers of analyzers, imaging equipment, and digital pathology scanners, and software. They are also the major drivers of the healthcare diagnostic enterprise.

UnitedHealthcare, on the other hand, views large health systems as suppliers and the U.S. government, corporations, and perhaps individual citizens, as its customers. They are the purchasers of health insurance and of health related services. The company views physicians as interchangeable cogs in the system and will not hesitate to bully them to in the pursuit of profits (see: UnitedHealth Moves Spark "Doc Fight"). Health systems are consolidating in order to gain more negotiating power vis-a-vis large insurance companies like UnitedHealthcare (see: Health Systems Use Their Regional Dominance to Muscle Insurance Companies). All of these three business models will certainly coexist, given the size of the large and profitable companies that are pursuing them. I compare them here in order to alert lab professionals to where I think their best interests lie.

Evidence that Roche Is Distancing Itself from the Traditional Pharma Business Model

I have previously blogged about Roche's interest and focus on companion diagnostics (see: More Details About Roche's Companion Diagnostics Strategy; A Closer Look at Companion Diagnostics Strategies; Consideration of a Broader Definition for "Companion Diagnostics"). This is a strategy whereby a company such as Roche co-develops, or recommends, a gatekeeper biomarker test or IVDMIA that qualifies a patient for treatment with a particular biotech drug manufactured by that company. Also keep in mind the company's recent purchase of BioImagene, one of the leaders in digital pathology. This allows the blending of digital pathology with the product line of Ventana. Now comes news that Roche is abandoning its relationship with the pharma trade association PhRMA and casting its lot with BIO, the biotechnology trade association (see: Special Report: Has Roche got the right medicine?). Here is an excerpt from the article:

[Roche] had just announced it was quitting the U.S. industry lobby group Pharmaceutical Research and Manufacturers of America (PhRMA) to join the biotechnology association BIO.It was a startling move by the youthful [CEO], a softly spoken lawyer by training with a background in economics. In effect, the boss was ditching Roche Holding AG's century-old identity as a traditional drugmaker and declaring it different from the rest of the industry....He argued that the future of his company, which had just bought the remainder of South San Francisco-based Genentech for $46.8 billion to become the world's biggest biotech group, was now firmly aligned to the Biotechnology Industry Organization (BIO). BIO's members, their business rooted in genetic engineering, had a jeans-and-sneakers approach far removed from the suits, traditional chemistry and mounting pricing pressures all too familiar to PhRMA members. Behind the spat was a fundamental question. Basel-based Roche was the biggest supplier of modern drugs for cancer, the hottest area of pharmaceutical research and development, and the leader in hi-tech diagnostics, the field that holds the key to the new era of personalized medicine. Was [he] making yet another smart move by throwing in his lot with biotech? Would the Swiss company now leave rivals in the dust as its profits and rating soared?

From where I sit, Roche's strategy can be summarized with the following four terms: biotech, cancer therapy, personalized medicine, and companion diagnostics. Here's my definition for personalized medicine from a previous note (see: Further Consideration of the Definition for Personalized Medicine):

Personalized Medicine: targeted diagnostics and therapeutics that incorporate the knowledge gained through evidence-based medicine as well as the individual and unique characteristics of the patient being treated.

I believe that classic Big Pharma has lost much of its steam and that Roche is moving in the right direction, at least in terms of the market, science, and profits (see: Some Evidence that Big Pharma Has Lost Its Innovation Mojo). However, what's the relevance of this new Roche direction for pathology and the clinical lab industry? Well, two of the global powerhouses in healthcare, Roche and Siemens, are now betting heavily on the future of medical diagnostics but in a slightly different way. The former envisions diagnostics as tightly intertwined with its pharmaceutical business and is placing great emphasis on IVD as well as automated tissue processing/tissue biomarkers with its Ventana division and digital pathology with BioImagene. The Siemens strategy is more of a pure integrated diagnostics play involving medical imaging as well as IVD. In both cases, there will be much more emphasis on diagnostics in guiding therapy and also assessing the efficacy of drug therapy. Previously, diagnostics was used primarily to arrive at a diagnosis of a disease. Pathology and lab medicine will derive large benefits from the pursuit of both of these models.

Why Does a Pathologist Request a Consultation on a Case; When Should This Be Documented?

In two previous posts, the issue has been discussed, firstly, how to document whether the consulting pathologists on a surgical pathology case should be documented in the report and, secondly, how to format this documentation (see: Displaying Pathology Consultants' Names and Opinions in Surgical Pathology Reports; Appending a List of Consultants to Surgical Pathology Reports). Michael Mihalik of Pathview Systems has responded to the second of these notes with a comment:

At the risk of displaying my ignorance to the world, why WOULD a pathologist want to note the consulting pathologist on a report? We obviously support this functionality, but I have always had this question.

I guess I have two general thoughts on the matter. The first is that is this not equivalent to the documentation of QC on a report? Obviously, I would not send out a diagnosis or result without QC being adequate. If I wanted further consultation on a case, that is my choice as the signing pathologist and would it not be customary for the requesting clinician to expect that such consultation would have occurred if there were any doubt. Document it 'yes', but put it on the report, 'why'.

My second thought about this practice is that it becomes yet one more item on a patient report, that is perhaps not particularly relevant to patient treatment. Imagine a report with a gross, microscopic, and diagnosis sections. Add an organ map, and perhaps a slide image or two. Finally, add a synoptic result section and a textual diagnosis as well. I have even gotten wind via the HL7 committees that a 'summary' section to a report might be in the offing. With all that data on a report, it's no wonder that I've had practicing pathologists approach me with the issue of 'having difficulties with physicians reading my reports and understanding the diagnosis to act on'.

To summarize, adding some notation that another pathologist was consulted on the report can often serve just to complicate the reading of the report. If anyone has other thoughts, I'd enjoy hearing another perspective. I am not a doctor and it would not surprise me that there is some perspective that I am missing.

It occurs to me, speaking in the first person, that there are three reasons for the primary pathologist to request a consultation on a surgical pathology case from a colleague, internal or external: (1) it's a somewhat difficult case about which I am confident; I simply want confirmation from the colleagues within my local group of my diagnosis; (2) it's a challenging case and I really need some assistance in arriving at a diagnosis from my colleagues in the local group; (3) it's an extremely challenging case; I and my colleagues in the local group have decided that it should be sent out to a well-known, external consultant for his or her opinion.

Although practices may differ, I suspect that, with regard to the first two of these examples, the report to the clinician may list only the primary pathologist. For reasons of internal documentation along the lines discussed by Dr. Alexis Carter in her first note, the names of the members of the group who reviewed the case may be documented for quality control reasons and subsequent review. There is probably an implicit understanding among the tissue-submitting clinicians in the hospital that the pathologists in the group will consult with each other on challenging cases.

In the last of my three examples above, I further suspect that the pathology group will want to convey the message in the report that the case was "extremely challenging" and, as a result, it was submitted to an well-known, external expert. This fact will often be documented in the report to the clinician at the possible risk of making it more complex. In most such cases, I think that the members of the local pathology group will defer to the judgment of the national expert even if it differs from their ideas. If they were not prepared to do so, why send the case to the outside consultant in the first place?

Academic Oncology and the "Chemotherapy Concession"

I recently came across an article discussing the difficulty in recruiting academic oncologists that brings to light some issues that are not commonly discussed in the literature (see: Why Academic Divisions of Hematology/Oncology Are in Trouble and Some Suggestions for Resolution). Below are two excerpts from it:

Academic divisions of hematology/oncology seem to have difficulty recruiting and retaining excellent productive clinicians. A major reason for this is that salaries do not compete with the private sector for similar work....The academic salaries are approximately one third of practice because the chemotherapy concession has been given to the academic hospital. In addition, there may be substantial problems in under-billing, lack of attention to detail in billing, and poor collection practices....Academic practice still has much to offer, including opportunities for research and multidisciplinary team management, although the differences may narrow over the coming years. Attention to detail in the billing, collection for work performed, and increasing academic salaries to levels nearer to private practice are necessary components of the solution to recruit and retain quality productive clinicians.
                                                   (and)
Chemotherapy is the only commodity sold from doctors’ offices. Some of our internist colleagues are incredulous that so much of the income comes from chemotherapy (one calls this "the dirty little secret" of oncology.) The ethics of this arrangement are complex, however. Without the revenue from chemotherapy, the office cannot run because so much nursing and support staff is needed; with it, the doctor has a potential conflict of interest to give chemotherapy and concentrate less on evaluation and management. It also means that without this concession, academic oncologists will never approach more than one third of private practice income.

One of the issues raised in this article is that oncologists are attracted to private practice because it is more lucrative due to the chemotherapy concession. This is the markup on the administration of chemotherapeutic agents to cancer patients that is paid to physicians in private practice -- it can be very lucrative. As succinctly noted in the second paragraph below, "chemotherapy is the only commodity sold from doctors’ offices. Here's more revelatory details about the chemotherapy concession from another article on the web (see: It's Still A Chemotherapy Concession):

Not only do the medical oncologists have complete logistical, administrative, marketing and financial control of the process, they also control the knowledge of the process. The result is that the medical oncologist selects the product, selects the vendor, decides the markup, conceals details of the transaction to the degree they wish, and delivers the product on their own terms including time, place and modality.

Hold on to your hats. The second issue raised above is that the employers of academic oncologists, the hospitals in which they practice, keep this concession money for themselves and underpay their oncologists, at least compared to the private sector earnings and in the opinion of the author. The third issue is that this oncology concession provides an incentive to treat/over-treat patients, particularly with very expensive drugs. This is referred to in the second paragraph delicately as "a potential conflict of interest." I raised this latter issue in a previous note (see: Some Tips for Selecting a "Good" Doctor and a "Good" Hospital) in which I advised readers with life-threatening problems such as cancer to seek care in academic cancer centers in order to avoid this conflict of interest and perhaps avoid over-treatment.

As to the problem of hospitals retaining most of the "oncology concession" revenue, there is not much that can be done about it. I believe that most private practice will soon disappear as the result of the triple juggernaut that we are facing: Big Pharma, Big Health Insurance, and Big Hospital Systems. As a whole, they constitute Big Medicine (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"). Almost all physicians will soon be working in some manner or other, directly or indirectly, for hospital systems. I also suspect that the "oncology concession" will soon diminish. This will be the inevitable result of negotiations between Big Pharma, Big Health Insurance, and Big Hospital Systems about how much it's really worth to treat cancer patients and with what chemotherapeutic agents