Britt’s note: This week’s post is from a former employee of Cancer Treatment Centers of America. After witnessing cancer care that seemed to him to be based purely on profit, the author left CTCA. Today the author is speaking out in order to provide an inside look at CTCA’s business model which demonstrates CTCA’s profit-centered mindset at the expense of patients.

While much of this information comes as no surprise to the skeptical readers who follow Orac’s not-so-secret blog and ScienceBasedMedicine.org, much of this information was new to me. I think the points are worth repeating because the inside perspective provides fascinating details about CTCA’s business practices.

Amongst naturopaths graduating from accredited schools, CTCA residency jobs are competitive and popular. These few positions offered at most of the CTCA hospitals around the country are amongst the rare “approved” residencies in naturopathic oncology. Naturopaths who complete a two-year residency at a site like CTCA are then eligible for board certification in naturopathic oncology which leads to the title “Fellow of the American Board of Naturopathic Oncology” (FABNO).

When I was considering naturopathic residency positions, I strongly considered a position at CTCA. I ultimately decided not to apply for the residency, in part, because none of employees I spoke with had anything positive to say about the hospital. I never researched anything about the CTCA organization to understand what the employees were trying to tell me. I now understand they were trying to warn me: stay away.

It is my hope that cancer patients, oncologists, and especially naturopaths heed the author’s warnings.

Cancer Treatment Centers of America

I am a former employee of Cancer Treatment Centers of America (CTCA). Because of the litigious nature of this company, I have chosen to submit this history anonymously. While I have deliberately left out any details that will help to identify me, the most damning of these facts are a matter of public record, and easy to confirm with a small amount of research.

I was an employee of the company for two-plus years during a period of rapid growth of the organization. I was involved as a non-management medical support person. Therefore, I was not a direct recipient of the types of perverse incentives that I will highlight here. They were well known around the office, however, and my first clue that things in this organization were not quite right.

The Business Model – The Original Sin of the Organization

Most cancer clinics, including any other that I’ve ever worked with, are owned by a hospital. The doctors who work there are either hospital employees, or part owners of the group, and the money goes into the overall operating budget of the hospital. Private practice oncology centers exist, but they are relatively rare in the community, and only offer certain services (e.g., chemotherapy) rather than a comprehensive package of diagnosis and management.

CTCA is a unique entity in the US – a fully for-profit chain of cancer hospitals or large outpatient clinics. This is an important thing to understand as we look at how they use these hospitals to serve a purpose that is at odds with standards of medical ethics.

Now, it is not necessarily proof of maleficence that the people involved in this company make a profit. I am not writing an economic manifesto here. But watch how every way that they deviate from standard medical practice appears very directly in response to the goal of maximizing revenue.

It is possible that this model no longer exists at CTCA. It is also possible that this was not a nation-wide CTCA policy. But during the time of my employment, this incentive-based revenue model drove much of the decision making at a very granular level. For example, that doctor who makes the critical decisions about whether or not another round of chemotherapy is likely to be of benefit? He gets commission from the company for each person treated. That naturopathic doctor who recommends the supplements? Gets a cut. The person on the phone trying to get you to come to the hospital? Yep, he profits too.

Again, I don’t mean to come on like Karl Marx. I understand that people deserve to profit from their education and expertise. But to tie specific financial incentives to decision making in the clinic sets up perverse incentives, ones I saw abused on a daily basis.

The Infomercial – Snake Oil on Late Night TV

If you’ve heard of Cancer Treatment Centers of America, it is likely through one of their television ads. These things carpet bomb late night TV, and always have the same general aesthetic. Basically, it’s a feel-good story of someone with a really bad diagnosis, where CTCA was the only hospital that offered any hope. Sweet, and fairly benign, right?

Except for this: picture that someone you care about just got news at another oncology office that the cancer was back, and that the prognosis is not pretty. If you are in that mindset, the ubiquitous CTCA commercials are like a dog whistle perfectly tuned to your frequency. Like the growth in the middle of your friend’s forehead, once you are tuned into this aspect of these commercials, it will be hard to ignore when you see them in the future.

There’s another level that these commercials play to, as well. Next time you see one, listen for that subtle “my other doctor gave up on me” message. This, again, is not an accident. Other oncology clinics regard CTCA about as highly as genital warts. Rumors around the halls were we polled at 5-10% approval among oncologists. So, CTCA needed to carefully drive a wedge between the patient and their current care team in order to drum up business. This is a gambit that the Tijuana clinics have used for years, honed to perfection.

Believe it or not, their ads used to be much worse. This was before a settlement with the Federal Trade Commission in 1996 required the company to be a little – just a little – more careful about the treatment claims they made.

We’ve Got a Live One Here – The Screening Call

This is where your CTCA experience begins. You call the 1-800 number on the infomercial, or perhaps you click a chat window on the corporate website. Then, you interact with a salesperson (a cancer information specialist in company parlance). This person is tasked with figuring out if you are a good candidate for a CTCA hospital.

You might be curious what the criteria for this decision is, and why it is left to a non-medically trained sales person to determine the answer. It’s pretty easy, really. The decision about whether you are a good candidate for a CTCA hospital is directly related to what insurance you have. Do you have an HMO or Medicaid? Sorry, you’re probably not such a good fit for our organization. A private plan? Out of pocket? Great, we’ll have a limo ready for you at the airport.

This sales technique was first reported publicly, at least as far as I can tell, by a brave former salesperson – er, cancer information specialist – named Carolyn Holmes. This is the same Carolyn Holmes who left CTCA under contentious circumstances and then filed charges against CTCA for unlawful termination. The case settled on May 8, 2015 but the terms of settlement are not publically available.

It’s really that simple. If you’ve got the right insurance, CTCA has a solution for you. Don’t believe me? Try calling their 1-800 number, and tell them that your wife/husband is very sick. Lay it on thick. Then, tell them that you have Medicaid. Click.

Alternative Medicine – The Bait

To see the company pitch on late night TV, you’d think that the clinic chain was an alternative medicine center. This is decidedly untrue, and very much a bait-and-switch tactic.

True, there is an alternative medicine clinic within each of the CTCA hospitals. Ours was a small suite of offices hidden away above the main lobby. In this area, we had a couple different types of providers – naturopathic doctors, acupuncturists, woo-woo psychotherapists. But everyone who worked in a medical capacity at the hospital knew that this department wasn’t where the bread was buttered.

In fact, the major difference between medicine at CTCA and other cancer clinics is not the use of alternative medicine, but their use of experimental medicine. I’ll define this as off-label or non-standard use of approved medications. For example, I remember hearing doctors trying to talk insurance companies into aggressive use of biologic agents (the most expensive class of chemotherapy) in cancer types that the drugs weren’t approved to treat. Similarly, our doctors were very aggressive in the use of expensive support medications like erythropoietin (EPO) and granulocyte-colony stimulating factor (GCSF) in ways that I have not seen elsewhere.

It is difficult to discuss the general role of complementary and alternative medicine in CTCA hospitals. For one thing, the scope of practice for alt med practitioners varies so much from state to state that the company doesn’t do the same thing in every area. Often times the scope of alt med care was defined by the comfort of the patient’s oncologist. For the most part, people who visited the alt med department would go home with a stack of supplements.

Of course, these supplements were privately branded, more expensive than comparable products, and can be purchased via the CTCA website. While the cost of supplements is dwarfed by the revenue generated by chemotherapy – a single month of treatment with one chemo drug may be as much as $30,000 – the idea of maximizing revenue by adding a couple of extra bucks to a vitamin is fully in line with the corporate agenda. I also know from a private conversation with one of these CAM providers that the company tracks supplement sales and pressures providers to keep sales up.

But the single biggest abuse I saw, and the reason why I no longer work there, was the use of very conventional chemotherapy regimens to treat patients who had already been through standard first and second-line therapies. Generally speaking, the more different chemotherapy medications that a patient has been treated with (also known as regimens that the patient has failed), the less likely that a new treatment will work. At some point in time, a compassionate oncologist will determine that the risk associated with further treatment will not be justified by the small chance at a transient clinical benefit.

Not so with CTCA, because they seem to never give up (on a patient with good reimbursement). As mentioned above, their TV commercials are perfectly designed to recruit a patient off hospice. It is the willingness to use low-yield chemotherapy regimens that keeps the patient from going immediately back to their previous clinic.

One problem with this treatment model is that it feeds into confirmation bias perfectly. I believe that I was able to be a part of the organization as long as I was – close to two years – because of the small number of patients who had remarkable responses to treatments that would not have been offered elsewhere. This blinded me to the ugliness of the company, until one day I began to see things more clearly.

I would love to tell you the story behind this day. It is very remarkable. It involved a nurse suggesting hospice to a patient who clearly needed to stop treatment, and several firings that followed in the wake. I fear if I give any more details, the company will figure out who I am and their lawyers will come after me. I don’t think this fear is unwarranted, even if I don’t exactly feel like a profile in courage at this moment.

The Tea Party Cancer Center – the Politics Behind the Company

Founder and CEO Richard Stephenson isn’t exactly known for his humanitarian beliefs. Stephenson is a primary funding source of Freedom Works, a large donor to Tea Party candidates, the very sort of candidates that help to remove the oversight on the insurance companies that CTCA is trying to maximize reimbursements from. Stephenson is an acolyte of Ayn Rand, the goddess of the libertarian movement.

Documents leaked from Freedom Works during the 2012 election cycle reveal that Stephenson is no small donor. Depending on who you believe, he may have pumped tens of millions of dollars into different candidates. This should speak to the massive profitability of this company. It should also speak to how much this company could potentially lose over cost-cutting measures in the Affordable Care Act.

Mr. Stephenson is almost cartoonishly enthusiastic about CTCA in person. Short, highly-coiffed, and energetic, he comes on like the railroad man from an old western. He exudes true believer about the company’s mission from every pore, and insists the same from everyone around him. Probably everyone that has worked under him for more than a month has heard the story about his mother’s death from cancer a time or two. It’s like the CTCA version of the Checkers speech, and about as sincere.

Side note: Stephenson claims that his mission at CTCA is directly related to his mother’s death from cancer. Contrary to public news sources, he actually bought the first CTCA hospital in 1975, seven years before this event. Like so much else in the corporation, his heart-warming story is utter bullshit.

From the top down, there is a cult-like atmosphere at a CTCA hospital. Lots of motivational emails, management meetings, and pep talks from the administrators help to keep the bubble tightly sealed, and any malcontents – or maybe apostates – are quickly shuffled out.

If you really want to know what motivates this company, look at the 2004 lawsuit brought by one of the original stockholders. In it, Stephenson is quoted as saying “The first priority is to protect the American International Hospital operations (now CTCA’s flagship hospital in the greater Chicago area) and keep them viable and profitable.” Hope, my ass.

Why It Matters

In 2015, CTCA expects to treat about 7000 new patients. Each of these patients will potentially be subjected to more treatment than community standards would deem appropriate, by doctors who are given incentives for each chemotherapy regimen prescribed. Alt med practitioners who financially profit from selling their services and supplements may also simultaneously dupe each of these patients into thinking CAM may help cure their cancer or increase their chances of survival. The company will take a portion of their massive profits and pour them into politicians who will turn a blind eye to this malignant scam.

It is well known from previous reports that CTCA manipulates patient survival data to show better than average survival rates. In part, this data manipulation might be done by cherry-picking patients and by excluding thousands of patients who didn’t receive the entirety of their care at CTCA.

I spend a lot of unproductive time thinking about which is more ethically dubious, the fringe therapies offered by people like Stanislaw Burzynski and Brian Clement or the more subtle abuses that go on at CTCA. I still don’t feel like I have a good answer for the question. In a nation with a legal system that only barely manages to respond to the worst frauds, I think it is very unlikely that anything substantial will happen to Stephenson and his organization for excessive treatment and the harm it creates.

Sources:

Reuters, 3/6/13 – Special Report: Behind a Cancer-Treatment Firm’s Rosy SurvivalClaims

Forbes, 12/31/12 – Making a Profit from Offering Ineffective Therapies to Cancer Patients

Delaware Court of Chancery Decisions, 2004 – Lane v Cancer Treatment Centers of America

FTC, 3/13/1996 – Companies that Purport to Successfully Treat Cancer Agree to Settle FTC Charges Over their Claims