If marketing materials are to be believed, the advantages of being able
to perform intensity-modulated radiotherapy can be worth as much as $6 million
in gross revenue per year to a urology practice. Setting up a pathology lab on
the premises can be worth another $1 million.
Generally, the practice of “self-referral,” or referring patients to healthcare
entities in which the doctor prescribing a procedure has an interest, is verboten by
the “Stark laws” that govern Medicare and Medicaid.
However, these laws leave open a loophole—for situations where such services
are provided by a member of the referring physician’s practice and when the services
are provided in the building that houses the practice.
In urology practices, the loophole covers pathology, radiation therapy and
diagnostic radiology.
How does ownership of a lab or an IMRT affect utilization of these services?
Two papers published in the April issue of the journal Health Affairs suggest that
self-referral increases the number of biopsies in urology practices that own labs, and
creates financial pressures that appear to direct patients with lower-risk prostate cancer
to receive IMRT. There is no data that would suggest that IMRT, which costs more,
is superior to other radiation treatments.
The first of the studies found that urologists are more likely to perform surgical
biopsies if they are able to self-refer, as opposed to referring such patients outside
their practices. This study was conducted by Jean Mitchell, a public policy professor
at Georgetown University.
The second study observed that IMRT is now just as likely to be used in men
with low-risk disease as in men with high-risk disease.
The proliferation raises concerns about overtreatment and increased costs—
since the therapy costs $15,000 to $20,000 more than standard care, said researchers.
The study was led by Bruce Jacobs, a fellow in urologic oncology, endourology, and
health services research at the University of Michigan.
Pathologists and radiation oncologists are unhappy with these changes in
urology, which cut into the services they have traditionally provided.
