Financial gain is driving referrals for specialist prostate radiotherapy, says report

BMJ 2013; 347 doi: (Published 08 August 2013) Cite this as: BMJ 2013;347:f4978
  1. Michael McCarthy
  1. 1Seattle

The financial interests of doctors and not clinical need are driving up the use of intensity modulated radiation therapy (IMRT) for treating prostate cancer, says a new report by the US Government Accountability Office (GAO).1

Major urological groups in the United States immediately denounced the report, calling it “a flawed, misleading study,” while the American Society for Therapeutic Radiology and Oncology, ASTRO, called it a “striking report” that “details clear mistreatment of patients who trusted their physicians to care for their prostate cancer.”

In the study investigators from the accountability office looked at the referral patterns of practices caring for Medicare patients with prostate cancer. They compared the referral patterns of practices that had no financial stake in an IMRT service, called “non-self referrers,” with those that did have a financial interest, called “self referrers.”

IMRT is a form of external beam radiation treatment in which the radiation beams are shaped to maximize the amount of radiation the tumor receives while reducing the amount to which normal tissue is exposed.

The treatment is substantially more expensive than other prostate cancer treatments, with the exception of proton therapy. The report said that one study, for example, found that the cost to Medicare per course of treatment of intensity modulated radiation therapy at about $31 500 (£20 300; €23 600) was nearly twice that of prostatectomy, $16 500.

It added that prostatectomy and other less costly approaches, such as brachytherapy and active surveillance, were appropriate alternatives to IMRT depending on the patient’s health, age, and other considerations.

The investigation found that from 2006 to 2010 the number of prostate cancer IMRT services performed by self referring groups rose from about 80 000 to 366 000 per year, an annual growth rate of 46%. During the same period, the number of IMRT services performed by non-self referring groups declined from 490 000 to 466 000, an annual decrease of 1%.

The accountability office said that acquiring a stake in an IMRT service appeared to change referral patterns. Groups that at the beginning of the study period did not have a stake in an IMRT service but then later acquired a stake, called “switchers” by the investigators, markedly increased the percentage of patients they referred to the treatment, from 37% in 2007 to 54% in 2009 after they had become self referrers.

During the same period, referral practices of those that were not “switchers,” that is, those that had either already been self referrers at the start of the study period or remained non-referrers over the same time period, were little changed, increasing from 31% to 33% among non-referrers and falling from 56% to 53% among the established self referrers.

Overall, the report said, by 2009 groups that self referred were 53% more likely to refer their newly diagnosed prostate cancer patients for IMRT than were non-self referring groups.

The investigators said, “Self referring providers also referred a lower percentage of their prostate cancer patients for nearly all other types of treatments compared to non-self referring providers, with the largest differences among patients being referred for brachytherapy or a radical prostatectomy.”

The GAO found that factors such as age, geographic location, and patient health did not account for the large differences between referral patterns of self referring and non-self referring providers. And almost all of the increase was due to referrals by limited group practices, consisting primarily of urologists, and not large multispecialty group practices, whose number of referrals for IMRT actually declined over the period studied.

“Taken together, our findings suggest that financial incentives were likely a major factor driving the increase of IMRT referrals among self referring providers in limited-specialty groups,” the investigators concluded.

The report recommended that Congress consider requiring self referring providers to disclose to their patients that they have a financial interest in the service, and that Medicare require providers to indicate when they bill for IMRT that the service was self referred so Medicare can monitor the effects that self referral has on costs and treatment selection.

The American Association of Clinical Urologists, the American Urological Association, and the Large Urology Group Practice Association issued a statement denouncing the report. It said that IMRT had become the “clinical standard of care” for the treatment of prostate cancer and that the shift to self referral was caused primarily by the growing number of group practices that incorporate radiation therapy into their practices in order to provide “comprehensive, integrated” care.

The urologists noted that the GAO provided no evidence that these practices were providing IMRT inappropriately.

Deepak Kapoor, president of the Large Urology Group Practice Association, said that the report “provides a skewed and incomplete picture of radiation utilization and expenditures and is of virtually no utility to health policy makers.”

In its response, the American Society for Therapeutic Radiology and Oncology said that the report’s recommendations did not go far enough and called on Congress to end the legal exceptions that allow urologists to refer their patients to IMRT services in which they have a financial interest.

Michael Steinberg, chairman of ASTRO, said, “It is acutely obvious that the self referral loophole must be closed to protect patients and to strengthen the Medicare program. This loophole endangers patients and erodes their trust in us as physicians.”


Cite this as: BMJ 2013;347:f4978