Fee-for-Service Research—a Preliminary Exploration

FEE-FOR-SERVICE RESEARCH—A PRELIMINARY EXPLORATION HOWARD M. SPIRO* Introduction In this article I will review the current status of fee-for-service research and some opinions about it. DEFINITION The term "fee-for-service research" was introduced by Stuart Lind in 1986 [I]. He defined fee-for-service research as the offering of experimental treatments to those who can afford to pay for them: those who can afford to underwrite its cost can have treatment tailor-made to their problem. The first, and so far only, example of explicit fee-for-service research for an individual patient is at a research facility in Franklin, Tennessee, where Dr. Robert Oldham, formerly of the National Cancer Institute, has established Biotherapeutics. For patients who have a fatal disease, usually cancer, who are fit enough to wait long enough (usually about a year) for treatment to be developed, and who can pay about $35,000 in advance, antibody programs against their specific tumor, or interleukin-2 (IL-2) treatments, can be developed. The details of the therapy are not important to present considerations. (Nor are the reactions of this amateur that cancer cells possess such remarkably cosmopolitan proclivities that antibodies built up against a collectivity of tumor cells at one time may not target the cells that are present in the next year. So variable are the growth and survival rates of different tumor cells in a single cancer that an analogy with early immigrants to America seems felicitous. In the seventeenth century it might not have been clear to a Martian whether the Dutch or the English or the Spanish would win colonial North America. So with cancer cells, it may not *Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 065 10.© 1988 by The University of Chicago. AU rights reserved. 003 1-5982/88/3 1 04-0599$0 1 .00 Perspectives in Biology and Medicine, 31, 4 ¦ Summer 1988 \ 589 always be possible to tell which cells in a given patient will dominate the lineage to supply the specific target.) The scientific merits of the procedure are not the issue; no one has raised any doubts at all about the scientific credentials of Oldham (I will drop the honorific) and his colleagues . It seems clear from published comments that no one criticizes the scientific merit of what seems to be the state-of-the-art tumor therapy in Tennessee. THE CURRENT COMMERCIAL CLIMATE To put fee-for-service research into current perspectives, I must devote a few paragraphs to the current commercial climate of medicine from the viewpoint of one graduated from medical school 40 years ago. Medical practice.—The past few decades have seen the for-profit motif and motive pervade the public image of medical practice in a way that was not so obvious in the 1940s. It was always there, some would suggest, but a veneer of charitable professionalism hid the fact that, like other professionals, doctors did, after all, have to earn a living. But in the 1960s, theory caught up with reality when physicians were first labeled "providers of medical care" to patients, who had become "consumers." Since then the power of metaphors to change outlook has been dramatically demonstrated in the increasingly obvious business orientation of medical care and practice. To look at the pages of medicaljournals or to listen in on conversations in doctors' dining rooms is to see how changed are even doctors' images of themselves. Television, radio, the newspapers carrying advertisements extolling "St. John'sJewish" or the doctors' services at "Mt. Aetna," are commonplace reminders that medical care, which was always profit seeking, has gone commercial in a big way. (A good example is an advertisement from the New York Times of October 12, 1986: "Prestigious Chicago medical center seeks an 'entrepreneur' as a Vice President of Clinical Services . . . the medical center looks to this pivotal position to implement and develop product lines and new business as it implements its newly developed strategic plan.") I do not use "commercial" in a pejorative fashion but only to describe what has happened —whether for good or bad being another matter. Nor do I want to join those who claim...