My urologist told me I needed a biopsy probably and then told me he had to disclose to me that he was a partner in the lab that did the biopsies. I didn't think much of it until I saw that he charged my insurance more than $7k for the biopsy. Of course he didn't collect that much in all probability.
Anyway, this is an interesting article on this issue and on the possible overuse of IMRTwww.medscape.com/viewarticle/761871
pasting it in case link doesn't work without registration:
From Medscape Medical News > Oncology
Financial Incentives Driving Prostate Cancer Testing and IMRT?
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April 11, 2012 — Two practices related to prostate cancer care and the way it is delivered by urologists have come under scrutiny in articles published in the April issue of Health Affairs. In both cases, physicians stand accused of profiting financially from self-referral.
One of the issues involves the diagnosis of prostate cancer from biopsies sent to pathology laboratories; the other involves the treatment of prostate cancer with high-intensity modulated radiotherapy (IMRT) instead of standard radiotherapy.
There is a federal law in the United States that prevents physicians from referring a patient to a service with which they have a financial relationship. However, an exemption can be made be if the physician is referring the patient to self-owned services in which they have a supervisory or managerial role, and if the services are provided in the same building.
Using this exemption clause, some urology practices have in-house pathologists to examine biopsy specimens taken from men suspected of having prostate cancer; others have invested in expensive systems to deliver IMRT to patients with prostate cancer.
Because these urologists stand to gain financially from using these in-house services, there is a concern that financial incentives are driving the use — and potentially the overuse — of these services.
Such concerns have already led several medical groups to lobby Congress to close the loophole in the law. Now these groups have fresh ammunition that self-referral is resulting in the overuse of in-house services.
Financial Incentives for Pathology Testing
The study on pathology testing of prostate specimens, by Jean Mitchell, PhD, economist and professor of public policy at Georgetown University in Washington, DC, analyzed data from 2005 to 2007. She found that self-referring urologists who have in-house pathologists billed Medicare for 4.3 more specimens per biopsy than the adjusted mean of 6 specimens per biopsy that nonself-referring urologists sent to independent pathology providers. This is a difference of almost 72%, she notes.
Although they sent more samples for testing, the self-referring urologists did not find any more cases of prostate cancer per patient than the group that used independent pathologists. In fact, the regression-adjusted cancer detection rate in 2007 was 12% higher for urologists who did not self-refer.
This suggests that financial incentives prompt self-referring urologists to perform prostate biopsies.
"This suggests that financial incentives prompt self-referring urologists to perform prostate biopsies on men who are unlikely to have prostate cancer," Dr. Mitchell concludes.
"These results support closing the loophole that permits self-referral to 'in-office' pathology laboratories," she added.
The study was immediately "applauded" by the Alliance for Integrity in Medicine Coalition, which includes a number of professional organizations, such as the American Society for Clinical Pathology, the College of American Pathologists, the American Clinical Laboratory Association, the American College of Radiology, and the American Society for Radiation Oncology (ASTRO). This coalition is actively urging Congress to close the legal loophole that allows self-referral.
This self-referral practice....provides no benefit to patients and only serves to drive up Medicare costs.
Dr. Mitchell's study is "particularly welcome," according to the coalition, because it provides independent peer-reviewed evidence that "this self-referral practice...provides no benefit to patients and only serves to drive up Medicare costs."
In a report of the study published April 9 in the Wall Street Journal, the newspaper quotes urologists who suggest that there are other explanations for the additional testing. The self-referring urologists might be more aggressive in testing because they are trying to catch the cancer earlier, said Steven Schlossberg, MD, from the Yale School of Medicine in New Haven, Connecticut, who heads a health-policy panel for the American Urological Association.
Overuse of IMRT for Prostate Cancer
The study on IMRT for the treatment of prostate cancer, by Bruce Jacobs, MD, and colleagues from the University of Michigan in Ann Arbor, suggests that there is an overuse of this technology.
IMRT is a fairly new. It delivers higher doses of radiation with better precision than other radiotherapies and is thought to have lower toxicity, but it also costs $15,000 to $20,000 more than standard therapies, the authors point out.
Does everyone deserve a Cadillac when a Buick is almost as good?
They liken the 2 approaches to cars, and ask whether, "in the context of limited resources, does everyone deserve a Cadillac when a Buick is almost as good?"
In their study, Dr. Jacobs and colleagues analyzed data on prostate cancer treatment from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. They found that when IMRT was first introduced in the United States (2001 to 2003), it was used mainly in men with high-risk prostate cancer; from 2004 to 2007, the use of this therapy became more widespread. During this period, men whose prostate cancer was considered low risk, and therefore less likely to be clinically significant, were just as likely to receive IMRT as men who were at high risk. "This raises serious concerns about
overtreatment," the authors note.
They suggest that "some physicians may view IMRT as an investment opportunity." Delivery of radiation has shifted from oncologists to urologists, they note, and some companies have been marketing IMRT aggressively to urologists as a revenue generator. "In this context, financial pressures induced by the considerable start-up costs may encourage IMRT in marginal patients," they add.
These comments drew a rapid response from ASTRO, which is one of the groups that has been lobbying Congress to close the loophole that allows self-referral.
A statement from ASTRO states that "IMRT yields benefits to prostate cancer patients through increased tumor control and fewer side effects," and that this "will ultimately reduce healthcare spending on prostate cancer and demonstrate the value of IMRT."
"At the same time, all patients may not be ideal candidates for IMRT, and patients should be presented with all of their options, including active surveillance," the statement reads.
In their article, Dr. Jacobs and colleagues note that Medicare reimbursement for IMRT is substantially more than for other radiotherapy.
According to ASTRO, this is because the technology is complex and requires more expertise, but the problem is not caused by the reimbursement rate of IMRT, which has declined by about
30% over the past 6 years. The problem is the overuse of IMRT in patients who don't need it.
Physician self-referral is significantly contributing to overuse of IMRT.
"Nearly 1 in 5 urology practices now own IMRT machines," ASTRO reports. "The expansion of these mega-urology practices can dominate prostate cancer diagnosis and treatment services in their market areas, and likely played a role in the growth of IMRT use during the study period."
ASTRO has several studies underway that it hopes will "shine light on how physician self-referral is significantly contributing to overuse of IMRT." In the meantime, the society says that it "will continue to work with Congress to close the self-referral loophole that leads to this abuse and ensure that all cancer patients receive the safest, most cost-effective cancer treatments."