August, 2013

Heightened Awareness

By Michael J. Katin, MD

Exodus, Chapter 5, 6-11

6 That same day Pharaoh gave orders to the slave drivers and the others who were in charge of the people. 7 He said, "Don't give the people any more straw to make bricks. Let them go and get their own straw. 8 But require them to make the same number of bricks as before. Don't lower the number they have to make. They don't want to work. That's why they are crying out, 'Let us go. We want to offer sacrifices to our God.' 9 Make them work harder. Then they will be too busy to pay attention to lies."
10 The slave drivers and the others who were in charge left. They said to the people, "Pharaoh says, 'I won't give you any more straw. 11 Go and get your own straw anywhere you can find it. But you still have to make the same number of bricks.'"

Our practices have been working hard to cope with the substantial cuts in the fee schedule imposed by CMS last year (9% overall for free-standing radiation oncology units) PLUS a 2% decrease due to the Sequester. It was unexpected that on July 8, CMS announced the proposed fee schedule for 2014, including a 5% reduction for radiation oncology professional charges and 13% for free standing unit technical charges!!!!!!! The explanation is that there is an attempt to cap our charges to a percentage of hospital charges, but with the lack of admitting that this is to 2013 hospital charges, not the increased allowances for them for 2014!!!!!!!!!

Just when you thought it was safe:

Will this finish off freestanding radiation oncology practices once and for all? This may be the coup de grace. We have heard of radiation oncology units trying to conserve by eliminating air conditioning, seeking out bargains on equipment such as examination gloves and patient gowns, and timesharing with other businesses, but while it may be difficult to make bricks without straw, it is impossible to make photons without paying the electric bill.

It's uncertain what motivated staffers to calculate that delivery of radiation oncology services will suddenly become less costly on January 1, 2014. Last year persistent communications from professional and patient support groups caused CMS to reassess and resulted in the reduction being 9% instead of 19% , and it will be critical to marshal these forces again.

Without being redundant without being redundant, it needs to be remembered that improvement in treatment of cancer and the desire to be able to offer these treatment options in the community setting led to the growth of community-based cancer centers, which now are at risk of needing to close because of an inadequate fee schedule. Unlike other businesses, it is difficult to make up losses by increasing volume or diversifying the product line.

I thought there was some hope when I learned that Dr. Ezekiel Emanuel had a statement published in The New York Times on March 23, 2013, cosigned by twenty-one other oncologists, entitled "A Plan to Fix Cancer Care." Here, at last, was the solution to delivery of treatment to those in need with a maximum of accessibility. Well, maybe not. In fact, the five-point plan is directed to revamp the payment system by eliminating fee-for-service, notifying physicians as to how much money is spent on tests and treatments, checking utilization, managing symptoms with nurses, and keeping new tests and treatments suppressed unless they clearly are effective. Obviously this should all be done, but there is no reference to #1 radiation therapy and #2 delivering treatment at the community level. This propagates the idea that all health care needs to be done in highly bureaucratic centralized settings It is probably a coincidence that every physician signing that document, with one exception, is affiliated with a large bureaucratic centralized facility.

Maybe there can still be some hope that those in power will recognize that the need for efficient delivery of cancer care is a real one and will possibly become more important in the future. It is interesting that in this past month two new risk factors for developing cancer have been recognized, in addition to everything that we already know is dangerous. A paper in Cancer Epidemiology, Biomarkers & Prevention reported a definite correlation between women's heights and the incidence of virtually every type of cancer This came from a study of 20, 928 postmenopausal women out of the 144,701 women enrolled in the Women's Health Initiative Program, . No method was able to be used to correct for slouching or for the use of stilettos. Men are not to take this lightly, since a similar study in 2010 from the
British Journal of Cancer had shown a correlation between height and the risk of testicular cancer and other studies have also described this connection as well as with other types, including prostate cancer The risk to the vertically endowed cannot be extremely high, considering that Robert Wadlow, Wilt Chamberlain, George Mikan, Manute Bol, and our two tallest Presidents, Abraham Lincoln and Lyndon B. Johnson, did not die of malignancies, but since average height has increased significantly over the past century it may be anticipated that cancer rates may increase as time goes on. A more significant danger may be in the widespread use of omega-3 fish oil. July, 2013, also saw the publication of an article in the Journal of the National Cancer Institute evaluating plasma phospholipid fatty acid in 834 patients with prostate cancer compared to 1,393 controls and found a substantially higher level of long-chain omega-3 fatty acids in the blood of persons with prostate cancer. Although this had been reported previously, this time the report about fatty acids spread like greased lightning (sorry) through the media and has already had major repercussions, with concerned boomers throwing out their fish oil capsules, restaurants changing their menus, and a dramatic drop in sales of the Bass-o-Matic. Ironically, increased ingestion of omega -3 fatty acids is encouraged by the American Heart Association to reduce the risk of heart attack and stroke. This then provides the dilemma to health care planners that if over the next 20 years omega-3 intake decreases there will be more people dying of cardiovascular disease and not living long enough to get cancer, but if it increases, there will be more people with good circulatory systems developing malignancies, especially prostate cancer. Then, if the population continues to get taller, it will turn out that all their projections will be inaccurate.

In other words, they will have been . . . caught short.