Oncologist who stood up to US insurance companies lost work

Editor—From early reports of the success of high dose chemotherapy and autologous bone marrow infusion some oncologists, including me, recognised that the procedure was far from proved, dangerous, and expensive.¹ I was a reviewer for several insurance companies at the time and rejected all requests for payment for both primary and metastatic disease. The companies welcomed the first few opinions, but when lawsuits started to be filed consultation requests decreased and then stopped. Yet other physicians were still being sent consultations.

I got the message. It was cheaper to grant payment than to fight in court and lose. But I could not change my opinion, because the evidence for effectiveness did not exist. I saw the lack of randomisation, the selected patients, the data from studies for other purposes—it was all there, and obvious.

I was near retirement and wanted to start a new career reviewing insurance cases for appropriateness of care, but as companies dropped me from their lists I could not obtain consultations. Fortunately, I was asked to head the oncology division at a teaching hospital. For the next six years until retirement I never referred a patient with breast cancer for high dose chemotherapy and autologous bone marrow infusion; the patients and I were all the better for it.

I recall the article on variations and attitudes of insurance companies in the New England Journal of Medicine, and was surprised that it was published.² Things were getting out of hand, and as a labouring doctor I had little voice. I suppose I was one of the few people not surprised at the final outcome in 1999.

I now investigate anomalous claims of the complementary medicine system. Here again, pressure groups, deluded elected officials, and officials lacking wisdom and principle are mandating payment for even more implausible methods.