GAO Report: Rad Oncs Thumbs Up, Urologists Thumbs Down
A new report on physician self-referral abuse in prostate cancer treatment has been met with a decidedly mixed response. Although one group has applauded the report from the Government Accounting Office (GAO), 3 urologic associations have resoundly condemned it.
The report found that physicians in practices that offer intensity-modulated radiation therapy (IMRT) services were more likely to refer Medicare prostate cancer patients for IMRT than for less costly treatments, such as conventional radiotherapy or radical prostatectomy. The concern is that such self-referral is driven by financial incentives rather than what is best for the patients, as previously reported on Medscape Medical News.
From 2006 to 2010, IMRT performed by self-referring groups increased rapidly — from about 80,000 to 366,000. In addition, related expenditures and the number of self-referring groups grew. During the same period, IMRT use by nonself-referring groups declined.
Reactions to the report have been swift and do not mince words. The American Society of Radiation Oncology (ASTRO) notes that the report details “clear mistreatment of patients who trusted their physicians to care for their prostate cancer,” and believes that the GAO report does not go far enough in its recommendations.
“We are extremely concerned that many older male patients are receiving such vigorous, possibly unnecessary, treatment by urology groups. Clearly, these self-referring urology groups are steering patients to the most lucrative treatment they offer, depriving them of their full range of treatment choices, including potentially no treatment at all,” said ASTRO chair Michael L. Steinberg, MD. “GAO’s findings also demonstrate that IMRT utilization would actually be declining if not for a small cadre of profit-motivated self-referring urologists.”
On the flip side, urology groups have jointly refuted the report as “incomplete, flawed, and misleading.” The American Association of Clinical Urologists, the American Urological Association, and the Large Urology Group Practice Association (LUGPA) issued a joint statement condemning the study and pointing out what they perceive to be serious problems.
Incomplete and Flawed
The urology groups say that the GAO provided no evidence that patients are being provided with IMRT inappropriately by integrated urology practices with IMRT capabilities. Of particular significance is the fact that the GAO’s own data show that the overall use of IMRT to treat prostate cancer has not changed since 2008.
“In its cost analysis, the GAO failed to acknowledge that any efforts to prevent physician practices from delivering integrated services, such as IMRT, will only shift the site of service of the exact same treatment to the hospital setting, where it will be reimbursed at higher levels, thus increasing costs and decreasing patient access to care,” they note in a statement.
Deepak A. Kapoor, president of LUGPA and chair and CEO of Integrated Medical Professionals, PLLC, stated that it is difficult to understand how “3 years of effort produced such a narrowly focused report.”
“For example, from 2007 to 2011, IMRT use to treat prostate cancer increased by only 2.2%, while IMRT use for other cancers during the same interval increased by 51.2%,” said Dr. Kapoor. “As such, the GAO report provides a skewed and incomplete picture of radiation utilization and expenditures and is of virtually no utility to health policy makers.”
The urologists emphasize that the GAO failed to properly account for the fact that the increased number of IMRT treatments performed by urology groups is directly related to the number of urology practices that offer radiation therapy as part of their integrated treatment strategies. In addition, the GAO “completely disregarded” peer-reviewed literature showing that IMRT is now the standard of care in this setting, they note.
Overused and Abused
However, ASTRO points out that the use of IMRT by self-referring groups increased by 456%, and that overall increases in IMRT rates and spending are “due entirely to services performed by limited-specialty groups [primarily comprised of urologists]. IMRT utilization among nonself-referrers decreased by 5%.”
The GAO report also found that the number of IMRT services performed by limited-specialty (urology) groups increased by 609%, whereas in true multispecialty groups, the use of IMRT decreased 3.8%, ASTRO notes. In addition, IMRT spending by self-referral groups rose by about $138 million, whereas spending by nonself-referral groups decreased by $91 million.
ASTRO suggests that the GAO report does not go far enough in its recommendations.
“The GAO’s own reports and numerous independent studies overwhelmingly affirm that self-referral results in financial incentives that lead to overutilization of healthcare services, unnecessary spending, and inappropriate care for patients.” They call on Congress to pass the Promoting Integrity in Medicare Act of 2013, which was introduced by Rep. Jackie Speier (D-California) and Rep. Jim McDermott (D-Washington) and would address GAO’s findings.
Rise in Self Referrals
The GAO was asked to conduct this review to answer questions that have been raised about the role of self-referral in the rapid increase in Medicare Part B expenditures.
The report notes that the percentage of prostate cancer patients referred for IMRT substantially rose in 2008, when self-referral began. In 2009, self-referring providers referred 54% of their prostate cancer patients for IMRT; in 2007, the same providers referred 37%. Providers who did not begin self-referring experienced much smaller changes.
The report notes that in 2009, self-referring providers were 53% more likely to refer their prostate cancer patients for IMRT, and less likely to refer them for other types of therapy, including a radical prostatectomy or brachytherapy.
“Factors such as age, geographic location, and patient health did not explain the large differences between self-referring and nonself-referring providers. These analyses suggest that financial incentives for self-referring providers — specifically those in limited-specialty groups — were likely a major factor driving the increase in the percentage of prostate cancer patients referred for IMRT,” according to the report.
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