The health care industry is faced with inadequate reimbursements, patients who can’t afford their co-pays, and a looming oncologist shortage. These are not academic problems for the nation’s 20,000 practicing oncologists or the more than 1.2 million Americans diagnosed with cancer every year.

Yet the American Society of Clinical Oncology last year turned to one of the nation’s leading medical schools for its new CEO. Allen Lichter, the former dean of the University of Michigan medical school, served as ASCO’s president in 1998-99 and chaired its Foundation board until 2002. Clearly, the radiation oncologist’s knowledge about the internal workings of the $55 million-a-year organization made him a logical choice for the group’s top administrative job, where he will earn approximately a half million dollars a year.

But the political battles facing oncologists in Washington are a far cry from the tenure and promotion dust-ups that enlivened his previous life in academia. There’s not much room for amateurs in a city where hundreds of millions of dollars in physician payments can ride on a single line of text in an appropriations bill.
So I recently paid a visit to ASCO’s plush offices in downtown Alexandria, across the river from the nation’s capital, to see how he’s adjusting to the tough questions being posed by legislators in Congress.

The best place to start was with the looming battle over the so-called sustainable growth rate in physician payments. If left untouched, the reimbursement formula for oncology services will lead to steadily declining reimbursements.

“This needs to be fixed,” he declared. “Doctors are receiving much less than it costs for infusion services. Everyone including CMS (the Center for Medicare and Medicaid Services) says that’s true. And the mark-up from drugs is gone.

“And Medicaid? The payment is so terrible that you’re doing it out of the goodness of your heart. And there’s a limit to how much you can do,” he said.

Yet some budget analysts argue that physicians in the United States, including oncologists, are paid significantly more than their colleagues in other countries, even after the costs of maintaining their practices. They’re asking if, as the United States heads into the budget-constrained years of the Baby Boom’s retirement, it doesn’t make sense to look at ways of reimbursing physicians other than traditional fee-for-service medicine.

“Physicians in this country have long been compensated better than their counterparts around the world where most people are salaried and there’s less of an entrepreneurial spirit,” Lichter said. “I spent most of my life working as a salaried physician and I worked hard. The Veterans Administration has thousands of salaried physicians. But thousands hang out a shingle and I presume they did that because they didn’t want the alternative. We see no reason to change that.”
How about the high cost of new cancer therapies? Is there anything oncologists can do in Washington to help their patients?

“Cancer care is very expensive, but that has been with us for a long time. Radiation therapy is in the $20,000 or more range. Most patients are well insured against catastrophic expenses,” he said.
But does it make sense for the health care system to pay up to $100,000 a year for drugs that may only extend life for a few months?

“Medicare is not allowed to do cost-effectiveness analysis, but individual doctors and patients do it all the time,” he said. “Most of these drugs that show a two to three month improvement have been tested in advanced patients. If you can move the needle in them, I’d say it is an unqualified yes for most patients. But early diagnosis is still key. These drugs are most effective with small amounts of cancer than with several pounds of cancer.”

My time was growing short, so I turned to an issue that has been in the news lately — whether physicians with ties to drug manufacturers should write clinical practice guidelines. Exhibit A: The controversy swirling around Procrit and Aranesp, the possibility that those drugs may actually be shortening patients’ lives. ASCO authors about three guidelines a year, and now has 27 listed on its Web site. Most writing committees included physicians with ties to industry.

“We’ve written a lot of guidelines over the last decade. We don’t want to retract a single sentence. They’ve all been stringently evidence-based,” Lichter said.
But wouldn’t the public have more faith in the process if the physicians who wrote those guidelines didn’t have ties to drug firms?

“The expert experts are usually involved with industry,” he asserted. “Could you do it (without them)? I don’t know. You would not produce the same quality of guideline. They’d miss the nuance. There are so many areas where the data is just not black and white,” he said.

My half hour was over. I came away disappointed. Issues like health care cost containment, drug safety and health insurance reform are going to play an important role in the upcoming presidential race. Perhaps it was too much to expect otherwise, but ASCO, which also is under new management, will represent oncologists as a special interest, not play a leadership role in solving these pressing problems.

Merrill Goozner is a contributing editor to Bay Area Oncology News.

—By Merrill Goozner

Posted on April 23, 2007 11:10 AM