Legislation Would Crack Down on Physician Self-Referrals

SAN FRANCISCO, CA - MAY 19: U.S. Transportation Secretary Ray LaHood (L) and U.S. Rep. Jackie Speier (D-CA) speak to reporters after touring a Pacific Gas and Electric gas line replacement construction site with on May 19, 2011 in San Francisco, California. Transportation Secretary Ray LaHood and U.S. Rep. Jackie Speier toured the San Bruno gas explosion site and a construction site where gas lines are being replaced. (Photo by Justin Sullivan/Getty Images)
National Journal
Sophie Novack
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Sophie Novack
Nov. 3, 2013, 7:29 a.m.

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.

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