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Concrete Options and Ideas for Increasing Value in Oncology Care: The View from One Trench

Massey Cancer Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA

Key Words. Cost of care • Quality of care • Palliative chemotherapy

Correspondence: Thomas J. Smith, M.D., Thomas Palliative Care Unit, Division of Hematology/Oncology and Palliative Care, MCV Box 980230, Richmond, Virginia 23298-0230, USA. Telephone: 804-828-9723; Fax: 804-828-8079; e-mail: tsmith5{at}mcvh-vcu.edu

Received July 17, 2009; accepted for publication September 15, 2009.

Disclosures: Thomas J. Smith: Consultant/advisory role: UnitedHealthcare, Inc.; Bruce E. Hillner: None.

The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the independent peer reviewers.

	ABSTRACT

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
In the U.S., medical oncology as a profession is wrestling with conflicting and often unrealistic clinical and financial expectations. Office-based practitioners face an environment of low reimbursement for cognitive care, high but declining reimbursement for chemotherapy and supportive care, and high income expectations of oncology professionals. As a field, there has been little incentive to assess or improve the quality of cancer care. Current incentives are often misaligned to reward doing the most aggressive and expensive actions, as long as patients are satisfied, because this leads to the highest return to the practice. Some consequences include U.S. cancer treatment costs that are twice that of any other nation with no or minimal differences in survival, late referrals (if at all) to hospice, and 14%–20% of patients receiving chemotherapy within 14 days of their death when it is highly likely to harm and cause complications. This pattern of care may lead to a significant risk for stress and burnout, as well as being economically unsustainable.

Systematic change to reward value requires realignment of incentives to provide episode-based care free from incentives to give expensive chemotherapy or supportive care drugs without good evidence, and an external board to determine appropriate patterns of care. The only ways to reduce the cost of care are to reduce either the amount of care or the cost of care, and either has dramatic consequences in a field that has been built on high expectations. These actions will likely control costs, but in the short term will cause significant distress among patients, families, and health care practitioners.

	INTRODUCTION

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
We were asked to approach the topic of "value in oncology" from the perspective of U.S. practitioners working within a local health system. We drew on our experience as both community practitioners and health service researchers to describe what we currently see, and what a vision of the future might be. For this report, we confine our remarks to palliative chemotherapy—the treatment of incurable illness [1]. The decision making to start, stop, and manage palliative chemotherapy reflects the majority of a medical oncologist's practice, and such treatments are less effective than those given for selected curable malignancies or as adjuvant therapy in breast or colon cancers.

Whereas many things are "right" with the profession—the explosion of new science and new drugs—there are many things wrong, too. In the U.S., we spend twice as much as any other country for the same overall survival results [2]. Almost all new interventions cost several-fold more relative to their added benefit than commonly accepted thresholds for "acceptable" incremental cost-effectiveness ratios. Over 90% of the cancer therapies approved by the U.S. Food and Drug Administration in the past 4 years cost >$20,000 for a 12-week course of therapy [3]. Given that there are about 100 new drugs in the pipeline being evaluated in phase III trials, that cost explosion is simply unsustainable [4]. There are impossible expectations for success placed on the oncologist by patients and their families, with little or no national recognition that cancer survival rates have changed minimally in the past years for patients with metastatic disease for most common solid tumors. Herein, we describe our perspective of the conflicting demands on the office-based practice of medical oncology and make recommendations for change.

	UNREALISTIC OR UNINFORMED DEMANDS FOR BENEFIT FROM PALLIATIVE CHEMOTHERAPY

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
Our group recently reviewed what patients know about their disease and how they make decisions [5]. Currently, most people are told the goals of care and their diagnosis. However, most people are not told if they are going to die from their disease, how long they have to live, or how to plan for their future. In a large recent report, only 37% of patients' families could remember any conversation with their oncologist about impending death [6]. As shown in Table 1, those who had had the conversation were much more likely to use less intensive or aggressive care and more likely to use supportive care. We are of the opinion that the appropriateness of the desired care for most patients dramatically improved, as well as leading to potentially tens of millions of dollars in cost savings to the overall U.S. health care system, just in the last week of life [7].

Currently, there are no readily available ways for the informed patient to get information about the anticipated benefit from palliative chemotherapy except from their practitioner. We know that decision aids work in oncology. Adjuvant! Online (http://www.adjuvantonline.com) was accepted by >85% of community adjuvant breast cancer patients. The decision aid helped them and their oncologists make better, more medically appropriate decisions, especially in low-risk patients [10]. There are no published decision aids for metastatic disease, simple tools for balancing benefit, toxicity, and cost when cure is not the goal, like there are for adjuvant therapy. We are working on those and have completed a pilot trial that shows average prognosis, treatment benefits, expected outcomes, and information on advance care planning. We are encouraged that the vast majority of patients want us to "tell me all" about diagnosis, prognosis, treatment benefits, treatment side effects, and options, and that hope was maintained in the face of bad news.

The "system" rewards trying to meet those impossible demands. Many patients and families take an attitude that as long as they are getting chemotherapy they are not dead yet, and there is always some hope for prolonged remission. Doctors find it incredibly hard to give honest information about prognosis, especially when they know the patient well [9, 11]. Doctors who give truthful prognoses and discuss the limited available options are burdened with negative affect that does not resolve over the day [12].

This avoidant behavior has its consequences. It is easier, and more financially rewarding, to continue giving chemotherapy until the end is beyond doubt. Our impression is that referral to hospice most commonly occurs only when the patient is no longer able to come to office, except by wheelchair if at all. In one study, comparable pancreas and colon cancer patients who switched to hospice earlier than their matched counterparts who continued chemotherapy did actually live several weeks longer [13].

	HIGH REIMBURSEMENT FOR CHEMOTHERAPY OR INFUSIONS

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
Reimbursement for infusions ("buy and bill," as one insurance executive stated) has been highly lucrative, based on the relative margin between acquisition costs and reimbursement rates. Figure 1 shows that, over the past 10 years, medical oncologist incomes have doubled and risen more than any other medical specialty. The increase in incomes of 86% occurred while actual patient visits increased 12%. This has led to Wall Street level salaries—$358,000 median and $523,000 mean (2006). The 90th percentile was >$1 million [14].

View larger version (17K): [in this window] [in a new window]   Figure 1. Rise in median incomes over the past 10 years. Based on information from Medical Group Management Association Annual Compensation Report; Englewood, CO: Medical Group Management Association, 2008:1–7; and Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: Why it matters. Ann Intern Med 2007;146:301–306.

There is good empiric evidence that doctors who own their own facilities use them two to eight times more frequently [15]. This has not been studied in modern oncology, where there may be more reason to do a computerized axial tomography scan every 2 months to assess chemotherapy response, but is unlikely to be much different.

The rapid growth of expensive supportive care drugs that are given in the ambulatory setting is under increased scrutiny. These include erythropoiesis-stimulating agents (ESAs), white cell growth factors, and bisphosphonates. Each of these classes of molecule has >$1 billion per year in U.S. sales. The relative extent of their use has been at least partially driven by their profitability to the practice. That is, no one gave ESAs to harm patients, but the benefits were small, the cost to society large, and the return to the practice even larger. In one practice known to the authors, profits fell by $5 million when ESA regulations were tightened.

All the current incentives line up to use expensive chemotherapy and supportive care drugs in U.S. oncology care, and against referral to hospice until very late in the game. The list of reasons and attitudes is long and entrenched, and includes: (a) lack of ways to inform patients (and/or patient acceptance) about the benefits and risks of palliative chemotherapy, (b) the "deep and abiding desire not to be dead" [16], (c) the fact that one third of patients persist in believing they can be cured even when conversations stating otherwise are documented [1], and (d) a common attitude that hospice should not be considered until chemotherapy options are exhausted. Although direct inferences cannot be made or linked, we believe that these reasons explain much of the evidence showing that 16%–20% of U.S. solid tumor patients receive chemotherapy within 14 days of their death. Although about one half of elderly cancer patients do use hospice, and hospice benefit is available for any patient with a prognosis of <6 months of life, the average user of hospice has services (or length of stay) of only 17 days, and one third has services of only 3 days.

	DO WE GIVE CHEMOTHERAPY TO MAKE MONEY?

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
The simple answer is "no." The one published study suggests that reimbursement does not influence the decision to give chemotherapy, just the specific chemotherapy that is chosen. This fits with our own personal observations that oncologists in academic centers, health maintenance organizations, and Veterans' Administration hospitals appear to have the same practice patterns across the board. However, in private practice, the more generous the reimbursement, the more expensive the chemotherapy we use (e.g., docetaxol instead of generic paclitaxel). Every $1 increase in reimbursement leads to a $23 increase in chemotherapy costs [17]. Medicare now pays 6% markup, which provides a natural experiment to see if reduced reimbursement leads to less chemotherapy use.

	LOW REIMBURSEMENT FOR COGNITIVE CARE

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
Whereas infusions of chemotherapy do generate substantial income, cognitive care does not. At $37 per work relative value unit (wRVU), the rate at our institution, an oncologist would have to generate >16,000+ wRVU to earn the U.S. average oncologist's salary. Given that the U.S. average is about 5,000, this oncologist would have to work far more than the 80 hours per week deemed safe for interns. In addition, this level of revenue would only cover the individual's salary, with no support for the other elements of the ambulatory enterprise—nurses, staff, social workers, counseling, billing, electronic medical records, and capital expenses. Realistic workloads for long, hard days based solely on cognitive services would lead to incomes <$200,000 per year despite the oncologist doing things no one else wants to do, like having difficult discussions. This would put the oncologist's overall compensation on par with a geriatrician.

	HIGH INCOME EXPECTATIONS OF ONCOLOGY PROFESSIONALS FOR VERY HARD WORK

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
For many of us, hematology/oncology is a 24/7/365 responsibility, unlike some other medical specialty practices. We have direct responsibility for outcome with the disease (at least a little bit), routinely deal with fractured dreams and extreme suffering, and are at risk for burnout. This is not something most oncologists would want to do for a low salary. There is a looming 40% shortage of oncologists, because there is more need with an aging population and treatments are getting more complicated [18]. Asking people to do the same difficult job for a markedly reduced salary may well reduce the attractiveness of the field. For example, take a typical office conversation with a 43-year-old breast cancer patient. She is the major breadwinner for the family and has two children. Her cancer has spread to the liver and lungs despite past therapy with anthracyclines, taxanes, and carboplatin plus cetuximab on a clinical trial. She is now facing the decision of initiating fourth-line chemotherapy. She desperately seeks any chance to stay alive to allow her to spend more time with her children and has not been, to date, overly burdened by chemotherapy toxicity–associated symptoms.

What is the reward for having difficult discussions on withholding chemotherapy, consistent with National Comprehensive Cancer Center Network (NCCN) guidelines (http://www.nccn.org), versus offering her gemcitabine or ixabepilone? Each of these single-agent drugs has a small but measurable probability of response, but has no impact on survival. The impact on you and your schedule is obvious: a 20-minute visit becomes a 60-minute visit with her in tears finally facing a finite future, and a feeling of failure—or at least great sadness—on your part. Most oncologists, if the truth be told, dislike discussions about "What do you mean, I am going to die? What will happen to my 5- and 8-year old? I will never get to see them grow up! There must be something you can do. I checked on the NCI's Website and it says there are treatment options. I will do anything, doctor!"

The impact on your practice in lost revenue (not necessarily profit) is relatively easy to measure—$1,000 or more for withheld chemotherapy, $600–$1,000 for withheld peglylated filgrastim, $800 for withheld zoledronic acid (given only with chemotherapy), and $600 for a withheld magnetic resonance imaging scan—compared with supportive care. It is a lot easier and less angst provoking to give fourth-line chemotherapy and your practice's revenue exceeds its overhead.

Believe us, it is easier to let the disease course play itself out, allow her to feel she has done everything, and then when the time has come switch to hospice. Sure, there are missed opportunities, but it is hard having those conversations without backup. In our role as palliative care team members, we have a whole team to support us; in the office, it is just us, running an hour late already, with no support. No one likes to break bad news, and discussing "futile care" is difficult [19]. Add breaking "bad" financial news [20] and the stress level increases. There are no successful models for managing all these expectations at the same time that do not involve major shifts in lifestyle, incentives, income, etc.

	GAPS IN THE ONCOLOGY EVIDENCE BASE

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
There have been surprisingly few studies of chemotherapy practice variation. For instance, how often do cancer patients receive third-, fourth-, and fifth-line chemotherapy, or do we give chemotherapy to people with an Eastern Cooperative Oncology Group (ECOG) performance status score of 3 or 4? Or, how many practices have model end-of-life care with hospice referrals >30 days?

On the clinical trial side, there is a great lack of governmental interest in practical studies of old versus new agents, or trials to show a treatment is as good but not as expensive. This is understandable; budgets are limited and noninferiority clinical and economic studies are huge, expensive, tough to accrue, and not exciting. We have had extremely limited success getting them done. Two examples have been our attempts to initiate trials comparing monthly zoledronic acid with zoledronic acid every 3 months for osteolytic bone metastases and a comparison of 12 weeks versus 52 weeks of adjuvant trastuzumab. For each trial, indirect comparisons suggest similar (or at least noninferior) efficacy and better safety.

	SUGGESTIONS FOR IMPROVEMENT

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
Provide Tools for Patients' Unrealistic Expectations for Benefit
It would be possible to revise the National Cancer Institute's Cancer.Gov to give prognosis and treatment information. That would allow the practitioner to give "average outcomes" for patients with a particular disease situation, for example, a 65-year-old healthy pancreas cancer patient whose cancer has progressed on gemcitabine chemotherapy. Although not individual specific, it would distill available clinical trial information to an average that could help the patient learn curability (or not), average lifespan (for planning), average treatment benefit, and the most common side effects (to balance whether to take it or switch to nonchemotherapy-based care), and the available clinical trials. It could add, for instance, "For those who want honest prognosis: about 95 of 100 people will be dead of their disease in one year. There is preliminary evidence that second line chemotherapy can increase survival by weeks or months, with acceptable toxicity, so some patients will opt for it [21]. When pancreas cancer recurs, it is good practice for the oncologist to offer hospice and palliative care as one alternative, for those who want to avoid chemotherapy toxicity and allow the best quality of life for the remaining time. You may want to discuss advance medical directives, a living will, a will, and address important spiritual and family issues."

The chemotherapy consent form could be modified to include treatment benefit estimates, as shown in Table 2. This would also document ECOG performance status. It is entirely consistent with prior American Society of Clinical Oncology (ASCO) recommendations that, before any treatment or technology can be recommended, there must be some evidence of objective benefit [22].

1. Calculate the effectiveness of a new drug.
   
2. Calculate the cost of a new drug.
   
3. Calculate the impact on the system: the number of users, what does it replace, opportunities for savings, special circumstances. (This is considered as "supplementary advice" for patients with a short life expectancy, normally <24 months, where the treatment offers an extension to life, normally of at least an additional 3 months, no alternative treatment with comparable benefits is available, and there are small patient populations.)
   
4. Calculate cost impact on the National Health Service.
   
5. Then there is a comment period, decision, and a revision schedule.
   

This is exactly what we do on our medical center's Pharmacy and Therapeutics Committee. Remember, there are >100 new drugs in randomized phase III trials, all with a price tag of thousands of dollars a month.

Address Low Reimbursement for Cognitive Care
This requires a substantial revision of the current system to reward good practice, not unsustainable entrepreneurship. One solution would be to pay all oncologists $50/wRVU (estimated from our own practice) for cognitive care, and pay our practice separately for registered nurses (based on duties, infusions given), psychologists, chaplains, and social workers. Funds for this would come from reduced chemotherapy payments to 6% over average sales price (ASP), for all payers.

Adjust High Reimbursement for Chemotherapy or Infusions
If the goal is to reduce the incentives to "overuse" chemotherapy and supportive agents, it is necessary to create "illness episode"-based payments. Some insurers are doing a pilot trial of this now, with essentially no profit from chemotherapy but maintained income (over the short term). Insurers would reduce reimbursement for chemotherapy to 6% over ASP and reward us for stopping chemotherapy at NCCN "switch to palliative care" points—second-line non-small cell lung cancer, third-line breast cancer, performance status score >2. For Medicare and Medicaid, use the Government purchasing power to reduce the cost of drugs.

Some needed research would critically examine the patterns of use of radiology/ancillary services and who owns the service centers.

Income Expectations, Stress and Burnout
As oncologists, we say we want to treat people, not disease. These changes all fit that model. Oncologists in other countries seem reasonably happy, productive, and appropriately numbered. In addition, survival is the same. A more stable salary might balance the lack of a huge "upside" salary.

Society generally acknowledges that it is incredibly hard to take care of sick people. That will not change. As people live longer with cumulative illnesses, there is more emotional exposure. If we can solve some of the unrealistic demands, that will help.

Saying no to fourth-line therapy may be viewed by some as explicit rationing. As stated previously, reforms need to make such therapy a revenue-neutral decision to the medical oncologist's practice as well as not putting the oncologist into the position of being the agent of bedside rationing without reasonable guidance and structural support from a NICE-like equivalent [23].

	CONCLUSIONS

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
Each of the listed problems has several solutions. For unrealistic demands for benefit, we can educate the public that not all cancers are treated successfully, and put honest information on websites. For low reimbursement for cognitive care, several models are being tested, including episode-based or monthly management fees. Similarly, the high reimbursement for chemotherapy is declining already. The income expectations of oncology professionals remain problematic, because the nonentrepreneurial practice reimbursements will not translate into the Wall Street level incomes seen over the last decade. The impact of this on the supply of oncologists remains to be seen. ASCO can take the lead here in defining what appropriate reimbursement should be, given the intensity of the work. The variable quality of care and little incentive to study it will be solved—payers will assess individual practice and practitioner variation. For stress and burnout, society should be mindful that the current clinical situation is stressful enough, without asking oncologists to solve society's financial problems.

It is impossible to make everyone happy. There are only two ways to reduce the cost of care—reduce either the care given or what is paid for it. Someone will see a significant change in their bottom line. Patients will not want to give up options, even long shots with considerable toxicity. The average citizen, patient, physician, and politician all do not want to publicly acknowledge the need for limits or rationing. We anticipate more evidence-based care with some limits (there really is no other way), but this will lead to short-term dissatisfaction on multiple fronts.

	AUTHOR CONTRIBUTIONS

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 
Conception/Design: Thomas Smith, Bruce Hillner

Financial support: Thomas Smith, Bruce Hillner

Administrative support: Thomas Smith, Bruce Hillner

Provision of study material or patients: Thomas Smith, Bruce Hillner

Collection and/or assembly of data: Thomas Smith, Bruce Hillner

Data analysis and interpretation: Thomas Smith, Bruce Hillner

Manuscript writing: Thomas Smith, Bruce Hillner

Final approval of manuscript: Thomas Smith, Bruce Hillner

	REFERENCES

Top Abstract Introduction Unrealistic or Uninformed... High Reimbursement for... Do We Give Chemotherapy... Low Reimbursement for Cognitive... High Income Expectations of... Gaps in the Oncology... Suggestions for Improvement Conclusions Author Contributions References

 

1. Harrington SE, Smith TJ. The role of chemotherapy at the end of life: "When is enough, enough?" JAMA 2008;299:2667–2678.[Abstract/Free Full Text]
2. Meropol NJ, Schulman KA. Cost of cancer care: Issues and implications. J Clin Oncol 2007;25:180–186.[Abstract/Free Full Text]
3. Fojo T, Grady C. How much is life worth: Cetuximab, non-small cell lung cancer, and the $440 billion question. J Natl Cancer Inst 2009;101:1044–1048.[Abstract/Free Full Text]
4. Hillner BE, Smith TJ. Efficacy does not necessarily translate to cost effectiveness: A case study in the challenges associated with 21st-century cancer drug pricing. J Clin Oncol 2009 [Epub ahead of print March 30, 2009].
5. Matsuyama R, Reddy S, Smith TJ. Why do patients choose chemotherapy near the end of life? A review of the perspective of those facing death from cancer. J Clin Oncol 2006;24:3490–3496.[Abstract/Free Full Text]
6. Wright AA, Zhang B, Ray A et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665–1673.[Abstract/Free Full Text]
7. Zhang B, Wright AA, Huskamp HA et al. Health care costs in the last week of life: Associations with end-of-life conversations. Arch Intern Med 2009;169:480–488.[Abstract/Free Full Text]
8. Chung HM, Lyckholm LJ, Smith TJ. Palliative care in BMT. Bone Marrow Transplant 2009 [Epub ahead of print January 19, 2009].
9. Dow LA, Smith TJ, Matsuyama R et al. Willingness of cancer patients to discuss advance directives with admitting doctor or oncologists. J Clin Oncol 2009;27(15 suppl):9539.
10. Siminoff LA, Gordon NH, Silverman P et al. A decision aid to assist in adjuvant therapy choices for breast cancer. Psychooncology 2006;15:1001–1013.[CrossRef][Medline]
11. Lamont EB, Siegler M. Paradoxes in cancer patients' advance care planning. J Palliat Med 2000;3:27–35.[CrossRef][Medline]
12. Panagopoulou E, Mintziori G, Montgomery A et al. Concealment of information in clinical practice: Is lying less stressful than telling the truth? J Clin Oncol 2008;26:1175–1177.[Free Full Text]
13. Connor SR, Pyenson B, Fitch K et al. Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage 2007;33:238–246.[CrossRef][Medline]
14. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: Why it matters. Ann Intern Med 2007;146:301–306.[Abstract/Free Full Text]
15. Kouri BE, Parsons RG, Alpert HR. Physician self-referral for diagnostic imaging: Review of the empiric literature. AJR Am J Roentgenol 2002;179:843–850.[Free Full Text]
16. Finucane TE. How gravely ill becomes dying: A key to end-of-life care. JAMA 1999;282:1670–1672.[Free Full Text]
17. Jacobson M, O'Malley AJ, Earle CC et al. Does reimbursement influence chemotherapy treatment for cancer patients? Health Aff (Millwood) 2006;25:437–443.[Abstract/Free Full Text]
18. Warren JL, Mariotto AB, Meekins A et al. Current and future utilization of services from medical oncologists. J Clin Oncol 2008;26:3242–3247.[Abstract/Free Full Text]
19. Khatcheressian J, Harrington SB, Lyckholm LJ et al. ‘Futile care’: What to do when your patient insists on chemotherapy that likely won't help. Oncology (Williston Park) 2008;22:881–888.[Medline]
20. McFarlane J, Riggins J, Smith TJ. "SPIKE$": A six-step protocol for delivering bad news about the cost of medical care. With apologies to Dr. Robert Buchman. J Clin Oncol 2008;26:4200–4204.[Free Full Text]
21. Oettle H, Pelzer U, Stieler J et al. Oxaliplatin/folinic acid/5-fluorouracil [24h] (OFF) plus best supportive care versus best supportive care alone (BSC) in second-line therapy of gemcitabine-refractory advanced pancreatic cancer (CONKO 003). J Clin Oncol 2005;23(16 suppl):4031.[Abstract/Free Full Text]
22. American Society of Clinical Oncology. Outcomes of cancer treatment for technology assessment and cancer treatment guidelines. J Clin Oncol 1996;14:671–679.[Abstract/Free Full Text]
23. Smith TJ, Bodurtha JN. Ethical considerations in oncology: Balancing the interests of patients, oncologists, and society. J Clin Oncol 1995;13:2464–2470.[Abstract/Free Full Text]
24. Medical Group Management Association Annual Compensation Report, 2008. Englewood, CO: Medical Group Management Association, 2008:1-7.

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This Article Abstract Full Text (PDF) eLetters: Submit a response to this article Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article link to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Reprints/Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Smith, T. J. Articles by Hillner, B. E. Search for Related Content PubMed PubMed Citation Articles by Smith, T. J. Articles by Hillner, B. E. Social Bookmarking                               What's this?