Study sees jump in self-referring urologists promoting radiation treatment

The scenario sounds familiar: A report has been released suggesting overuse of services by specialists who profit from self-referral of patients for intensity-modulated radiation therapy, or IMRT. Oncologists are hailing the findings. Urologists are condemning the flaws in the study.

Last August, the IMRT self-referral report came from the U.S. Government Accountability Office. (A similar report on spinal devices supplied by physician-owned distributors was just released.)

The most recent report on physicians profiting from IMRT self-referral was published in the New England Journal of Medicine, and it found that the rate of IMRT use by self-referring urologists in private practice grew from 13.1% to 32.3% between 2005 and 2010, compared with growth from 14.3% to 15.6% among nonself-referring urologists. The report was written by Georgetown University economist and public policy professor Jean Mitchell, who has written extensively on self-referral issues—including issues relating to urologists.

Her recent NEJM study was financed by an unrestricted educational research grant from the American Society for Radiation Oncology, also known as ASTRO. It compared IMRT utilization rates between 35 self-referring private-practice urology groups and 35 nonself-referring private-practice urology groups. She also compared rates from 11 other private practice self-referring groups with nonself-referring urologists employed at 11 National Comprehensive Cancer Network centers.

“This study shows that men treated by self-referring urologists, as compared with men treated by nonself-referring urologists, are much more likely to undergo IMRT, a treatment with a high reimbursement rate, rather than less expensive options, despite evidence that all treatments yield similar outcomes,” Mitchell concluded. “The findings raise concerns regarding the appropriate use of IMRT, especially among older Medicare beneficiaries, for whom the risks of undergoing intensive irradiation probably exceed the benefits.”

In a news release, ASTRO Chairwoman Dr. Colleen Lawton said she and other prostate cancer specialists use “these powerful technologies,” but they do so “prudently” and in a manner suiting the best interest of individual patients.

“Dr. Mitchell's study provides clear, indisputable evidence that many men are receiving unnecessary radiation therapy for their prostate cancer due to self-referral,” Lawton said in the release. “We must end physician self-referral for radiation therapy and protect patients from this type of abuse.”

The American Urological Association released a statement noting that it welcomes the opportunity to constructively discuss the issues involved. “Unfortunately, given its inherent biases and flawed methodologies, Dr. Mitchell's article does not contribute to the discourse,” according to the association.

Specifically, the AUA criticized Mitchell's selection of control groups and said “one cannot help but wonder whether Dr. Mitchell chose the control groups to arrive at results that were acceptable to the study's sponsors.” The AUA further pointed out that it released a set of guiding principles for its members to follow for in-office ancillary services this year that call for transparency and advising patients that they are entitled to second opinions.

The Large Urology Group Practice Association also denounced the study and said it achieved “bizarre results” and was an attempt by ASTRO “to persuade lawmakers to legislate a monopoly for its members in the use of radiation therapy to treat prostate cancer.”

(In August, publication of the GAO report was followed by legislation introduced in the House of Representatives, titled the Promoting Integrity in Medicare Act of 2013 (PDF), that would ban self-referral for advanced imaging, anatomic pathology, radiation therapy and physical therapy. It was referred to the House Energy and Commerce Committee's subcommittee on health where no action has been taken.)

While the two sides either cheered or condemned the study, Amitabh Chandra, a professor of public policy at Harvard University's John F. Kennedy School of Government, expressed a third view on Twitter.

“NEJM article on IMRT highlights something else too: that the vast majority of physicians hold the line despite incentives to do much more,” Chandra tweeted.

Follow Andis Robeznieks on Twitter: @MHARobeznieks