Conflicts of interest in recommending chemotherapy

I am fortunate (I think) to be part of a practice in which the physicians do not get direct revenue from chemotherapy. I don't completely understand it, but it has something to do with the fact that our chemotherapy room is physically located in our hospital, and so the hospital gets the money, and the administration uses that sum of money to pay everyone their fixed salaries.

I believe this takes out of the picture any bias or influence that may be introduced in my recommendation for (or against) chemotherapy. Certainly, those in private practice make (a lot) more money than I do, but at the end of the day I like this arrangement that we have, because I can honestly say my reimbursement does not factor into my treatment recommendations.

However, it has previously been recognized that the way chemotherapy is paid for in the United States is a potential financial conflict of interest for medical oncologists. Some prior work has shown that there may be some influence on which drug is used, but not on whether to use chemotherapy or not — which jives with what I have noticed when giving second opinions. Doctors are not giving chemotherapy to poor performance-status patients, for example, who clearly should not have chemo treatments. But when some chemo may be in order I frequently see that the newest, most expensive drug is used (the "Wondermycins" of the world, as our bioethicist Norm Fost, MD, MPH, calls them).

So, I turn your attention to this recently published "very open letter from an oncologist." I'm interested in your opinion. Either leave a comment, or email me directly: ns3@medicine.wisc.edu.