Dr. Conti Replies

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Dr. Watson states that my assertion that physicians gain profit from the administration of chemotherapy in private practice is “absurd.”

Recent reports from the Oncology Circle practices [a data-sharing collaborative of best-in-class oncology practices from across the country] suggest that current drug profit margins average between 15% and 25%. As Dr. Watson suggests, these profits likely vary among practices by payer mix and geographic location. They are also used by practices to pay for other practice costs including physician salaries. 

Main Argument Clarified

My main argument is a different one: Recent reform efforts by Congress (such as the average sales price reimbursement declines associated with sequestration) and by payers (such as episode-based payments) are targeting the drug profit margins of outpatient oncology practices. To keep afloat and even thrive under these changes, practices will need to evolve new financing models where chemotherapy administration is not the main source of practice costs and profits.

I am not sure what Dr. Watson’s disagreement is with my argument regarding the impact of evidence on chemotherapy usage. National Comprehensive Cancer Network (NCCN) guidelines, ASCO recommendations, and the dissemination of other evidence are clearly important determinants of chemotherapy usage. In one paper published in the Journal of Clinical Oncology,1 my colleagues and I estimated that approximately one-quarter of off-label use of 10 infused or injected chemotherapies is associated with NCCN guideline–consistent care. In another paper published in Medical Care,2 my colleagues and I estimated dramatic declines in the use of bevacizu­mab (Avastin) for the treatment of metastatic breast cancer after the U.S. Food and Drug Administration’s review of the evidence supporting its use, particularly among physicians in private practice. 

What oncologists are missing under the current system is systematic evidence regarding their patients’ out-of-pocket costs associated with chemotherapy treatment and comparative effectiveness data on outcomes for real patients across available treatment options. If these data were available and widely disseminated, the evidence suggests oncologists would use them to help guide treatment decisions among their patients and for their practices more generally. ■

—Rena Conti, PhD
Assistant Professor of Health Policy
and Economics

Departments of Pediatrics and
Public Health Sciences
The University of Chicago


1. Conti RM, Bernstein AC, Villaflor VM, et al: Prevalence of off-label use and spending in 2010 among patent-protected chemotherapies in a population-based cohort of medical oncologists. J Clin Oncol 31:1134-1139, 2013.

2. Conti RM, Dusetzina SB, Herbert AC, et al: The impact of emerging safety and effectiveness evidence on the use of physician-administered drugs. Med Care 51:622-627, 2013.

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