Officials with the Government Accountability Office (GAO) may have discovered a disturbing trend among doctors within the U.S. Medicare system who self-referred patients for radiation treatment and put a strain on the federal program.
After scrutinizing all claims made under the Medicare B system, GAO administrators saw a pattern among doctors who stood to gain financially from prescribing radiation for cancer patients: doctors who were able to self-refer intensity-modulated radiation therapy, or IMRT, did so at an alarming rate.
“One of our major concerns was for patients who rely on the advice of the doctor they are going to,” said James C. Cosgrove, director of health care initiatives for the GAO. “If a doctor is recommending one treatment over another, we think it is important for the patient to know that their doctor has a financial interest in prescribing one treatment over another.”
The report was the third in a four-part series examining issues surrounding physician self-referrals.
The first installment looked at doctors who were able to self-refer advanced diagnostic imaging, such as MRIs or CT Scans. That study was followed by a second investigation aimed at self-referrals of anatomic pathology, or treatments related to urology, dermatology, and gastroenterology.
The final report will look at self-referrals for physical therapy and is expected this fall, according to Cosgrove.
The GAO tested several theories to explain why radiation therapy prescriptions increased from 80,000 in 2006 to 366,000 in 2010.
Investigators attempted to find a pattern among patients’ ages, health status and geographic location, even studying sub-sets of patient data from New York, where an advanced tracking system can even tell researchers what stage of cancer patients were at when they were prescribed IMRT. They turned up no reason for the increase.
Finally, they began tracking doctors with and without the ability to self-refer.
“One category was for physicians who didn’t self-refer IMRT at all during the period. Another group was made up of physicians who did self-refer the entire period,” he said. “The third group was for those who began the period not self-referring, but somewhere in the time period they became self- referring.”
Those in the latter group were doctors who either acquired the capacity to do the treatment, or joined a group that was providing the treatment, during the period of the study.
“What we saw was that the ‘switchers’ increased the proportion of patients they were sending for IMRT by 47 percent,” Cosgrove said. “What it came down to was that this is an expensive service and the doctors are getting paid for it.”
Other treatments for prostate cancer include hormonal therapy or a prostatectomy, according to the National Cancer Institute.
According to the GAO, the increase in self-referrals has put an exorbitant strain on the Medicare system. The agency’s earlier report on anatomic pathology self-referrals concluded that the practice cost Medicare roughly $69 million between 2004 and 2010.
However, the U.S. Department of Health and Human Services disagreed with the GAO’s findings, and its recommendation that doctors be required to indicate on Medicare forms whether they had self-referred patients for the radiation treatment.
“HHS does not concur,” the department said in a response. “We do not believe this recommendation will address overutilization that occurs as a result of self-referral.”
“We believe that adding self-referral a flag on the Medicare Part B claims form and requiring physicians to indicate whether the service is self-referred will be complex to administer and may have unintended consequences,” department officials wrote. “We believe that other payment reforms will better address overutilization than a new checkbox on the claim form.”
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