A new study shows a sharp increase in the use of intensity-modulated radiation therapy to treat prostate cancer when the doctor benefits financially through self-referral, and a House bill aims to crack down on such profit-driven health care practices.
The study, published last week in the New England Journal of Medicine, found a 146 percent increase in IMRT services among urologists who self-refer. Comparing Medicare claims between 2005 and 2010, there was a 19.2 percent increase in IMRT use among self-referring groups once they became self-referrers, versus a 1.3 percent increase among physicians who did not self-refer.
The physician self-referral law, called the Stark Law, prohibits physicians from making referrals for certain health services covered by Medicare to entities with whom they have a financial relationship. Yet the law has an exception for "in-office ancillary services," which includes radiation therapy.
However, IMRT is not always the best treatment for prostate cancer as far as cost or health, and can actually be harmful to older beneficiaries, according to the author of the study, economist Jean Mitchell, a professor at the McCourt School of Public Policy at Georgetown University.
Mitchell says the ancillary-services exception has resulted in a growing number of urology groups gaining ownership of IMRT services.
"[The exception] enables physicians and physician groups to incorporate designated health services — including radiation services — into their practice without violating the law," she said. "This self-referral arrangement is linked to increased use of health services and also health care spending, with no clear benefit to patients."
Rep. Jackie Speier, D-Calif., introduced a bill in August along with Rep. Jim McDermott, D-Wash., and Dina Titus, D-Nev., called the "Promoting Integrity in Medicare Act of 2013" to address this issue. The bill would prohibit self-referral for radiation therapy, advanced imaging, anatomic pathology, and physical therapy.
"This is unnecessary, inappropriate, and in some cases even harmful treatments or services," Speier said. "This is not about better care and not about patient convenience, it's really about making a buck."
The study has received pushback from some urology associations, including the American Urological Association and Large Urology Group Practice Association.
"The AUA is committed to ensuring the delivery of appropriate, high-quality health care to men with prostate cancer and welcomes the opportunity to discuss these issues in a constructive manner. Unfortunately, given its inherent biases and flawed methodologies, Dr. Mitchell's article does not contribute to the discourse," the organization wrote in a statement.
AUA declined to offer further comment.
According to Speier's office, she is building support for the bill, though some resistance has come from doctors who currently benefit from self-referral. It remains unclear if or when it will get a hearing as a standalone bill, but Speier sees it as a potential sustainable growth rate pay-for. This would mean attaching it to permanent "doc fix" legislation, so the Medicare savings from her bill would go toward covering those costs. Legislation to permanently repeal the SGR has broad bipartisan support, though how to pay for it remains uncertain.
Speier says her bill would restore the original intent of the Spark Law. "I'm hoping this study draws specific attention to my colleagues that something needs to be done," she said.