When Kenneth Baker found out he had prostate cancer, his urologist detailed his options: The 84-year-old was too old for surgery, but he could pick from two forms of radiation or simply wait to see if he really needed treatment.
The wait-and-see option didn't appeal to the retired salesman. But Baker was drawn to a radiation regimen he could undergo at a center his urologist's practice had opened near his home outside Baltimore.
"The setting and the waiting room was just like a family room," said Baker, who recently finished radiation therapy at the Chesapeake Urology Associates Prostate Center, one of dozens of centers around the country that urologists have opened offering patients with the common malignancy an expensive, relatively new treatment known as intensity-modulated radiation therapy, or IMRT. "I felt very comfortable there," Baker said.
Proponents of such centers argue that they bring together specialists to help patients make the best-informed decisions and that IMRT can be lifesaving. But the centers have become the focus of rising scrutiny. Critics charge that they are a disturbing development in an alarming trend: doctors in many specialities referring patients to facilities in which they have a financial interest, possibly leading to unneeded and sometimes dangerous procedures and adding to the nation's bloated medical bill.
The Maryland Board of Physicians was set to announce Monday that radiation therapies such as IMRT for prostate cancer are covered by the state's "self-referral" law, which restricts doctors from referring patients to facilities in which they have a financial interest. The board's decision, which was made last week, means it will investigate complaints it receives about doctors allegedly referring patients for radiation therapies in violation of the law, said Paul T. Elder, the board's chairman.
"It is our intention to enforce the law. Our intention is to put people on notice, both patients and practitioners, that if there is a self-referral practice out there, it needs to be stopped," Elder said. "We don't want to be draconian about this. We don't want to frighten people. But we do need to let them know that we do intend to enforce the law.
Two coalitions of doctors groups, including Chesapeake Urology Associates, have been challenging the state's restrictions in the courts and are now backing a bill introduced last month in the Maryland General Assembly that would amend the current law, which the Maryland Court of Appeals upheld in January. Elder says the board has no information about whether any practices in Maryland will have to make changes because of the law. Chesapeake Urology officials said they will look carefully at the board's ruling.
Meanwhile, the U.S. Government Accountability Office is launching a probe into the practice of self-referrals nationally that will focus in part on IMRT for prostate cancer, GAO officials said. "We need to figure out what's best for patients, not the bank accounts of urologists and radiation oncologists," said Rep. Pete Stark (D-Calif.), one of three lawmakers who requested the inquiry.
At the same time, the Medicare Payment Advisory Commission (MedPac), which advises Congress about the massive federal health program, is in the early stages of considering recommending action to discourage overuse of a variety of doctor-owned services. The steps are aimed primarily at costly and sometimes potentially dangerous diagnostic tests such as MRI and CT scans, but they could affect some radiation oncology services.
In the case of IMRT, critics argue that urologists are exploiting the allure of the latest therapy to profit from federal reimbursements and private insurance.
"I think it's one of the biggest scandals in America today," said Peter D. Grimm, executive director of the Prostate Cancer Treatment Center in Seattle. "Do you want your dad going to somebody who has a very highly incentivized reason to give him one particular treatment that is not necessarily in his best interest?"
Proponents argue that the IMRT centers offer patients convenient access to a variety of experts offering every available option. Financial incentives never influence the care anyone receives, they say. In fact, they say, the centers exemplify the kind of "integrated" care that is the future of a more efficient health-care system.
"What we offer is a comprehensive level of service where patients are able to access the highest level of care in a community practice setting," said Deepak A. Kapoor, who chairs Access to Integrated Cancer Care, a Washington-based group that his center, Chesapeake Urology and other urology groups formed in 2009 to represent their interests in Washington. Kapoor also heads Integrated Medical Professionals in New York, the largest of these centers.
'Perverse incentives'
The practice of doctors' referring their patients to their own facilities was contained by legislation that Stark first sponsored in 1989. But the law permits doctors to "self-refer" patients in cases where it makes sense to quickly diagnose and treat some conditions.
"It's being exploited throughout the health-care system. The gastroenterologists are doing it. So are the dermatologists. Every ear-nose-and-throat doctor seems to have their own CT scan machine. It's a huge driver of overutilization," said Jean M. Mitchell, a health economist at Georgetown University. Mitchell is planning to soon publish a study showing that urologists who perform - and receive payments for - their own pathology services are more likely to order biopsies and to take more tissue samples for analysis.
The exception is especially being taken advantage of by some of the large physician-owned urology groups that have opened in at least 19 states in recent years, critics say. The centers began to proliferate after Medicare slashed payments for Lupron, a hormone drug for prostate cancer that had become a major source of income for many urologists, they note.
Instead of referring their patients to independent radiation oncologists or hospitals, some urologists began to lease or buy IMRT facilities, which officials say can cost at least $3 million, and hire or partner with radiation oncologists.
As a result, they can receive at least $30,000 and as much as $95,000 per patient for IMRT, compared with only about $1,500 to $7,000 for surgery or an older form of radiation known as brachytherapy, or radioactive "seeds," according to Daniella Perlroth, an academic research associate at Stanford University's Center for Health Policy/Primary Care and Outcomes Research. Kapoor and others question those estimates.
Anthony L. Zietman, a professor of radiation oncology at the Massachusetts General Hospital in Boston and the chairman of the American Society for Radiation Oncology, said the arrangements were "creating perverse incentives."
IMRT was developed to reduce the risk for impotence, incontinence and other complications that can result from surgery and other forms of radiation by using computer-controlled linear accelerators to precisely target the tumor.
Studies indicate the approach is effective. But because prostate cancer often progresses very slowly, research has shown that many men, especially older men, can simply wait to see if they need to be treated. IMRT also may be questionable for some younger men since debate continues over how well it works and how the side effects compare with alternatives in the long run. IMRT can leave some men impotent and suffering from bowel and bladder incontinence, experts say.
"I have certainly seen young, otherwise healthy patients who should have been offered surgery as an option and older patients who should have been offered observation, and they were given only one option, which is treatment at their center," said Patrick C. Walsh, a professor of urology at Johns Hopkins Medical Institutions in Baltimore, without naming any specific physicians. "I can only conclude the reason for this was a for-profit motive."
According to an analysis by MedPac, Medicare payments for radiation therapy for cancer to physicians outside hospitals who were not radiologists or radiation oncologists jumped 84 percent - to $104 million - between 2003 and 2008. Urologists were among those at the top of the list of non-radiation oncologists or radiologists getting reimbursed for these treatments.
Another analysis found that the proportion of prostate patients being referred for seed therapy plummeted in one central Pennsylvania community after an IMRT center opened in 2007.
The patient's choice
Proponents argue that most of the criticism comes from radiologists and radiation oncologists protecting their turf. IMRT use is increasing, along with surgery for prostate cancer, the proponents maintain, because more patients are recognizing the superiority of those options.
"Nothing is more important to Chesapeake's doctors than providing our patients with all the information they could possibly want or need to make the best possible choice for themselves and their family about what kind of treatment if any they receive - whether that be from us at Chesapeake or from any other doctor," said Sanford J. Siegel, president and CEO of Chesapeake Urology in an e-mail.
"Mr. Baker was provided with all of the appropriate options . . . at the Prostate Center for his prostate cancer care. The final treatment path was chosen by Mr. Baker," Siegel said. Like all patients, Baker signed a form acknowledging his urologist's financial interest, according to Siegel.
Baker has no doubts he was fully informed about his choices and picked the one best for him.
"No one tried to steer me," Baker said. "They gave me all the options and let me make the decision. This put the radiation where it's supposed to go. It felt like the only really good option."
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