Organized urology finds allies on self-referral

Washington-As the pressure continues to build in Washington to tighten the screws on the in-office ancillary services exception (IOAE) to provisions of the Stark self-referral law, key organizations representing urology are looking for allies on Capitol Hill to preserve that piece of business for urologists.

In late June, AUA Health Policy Chair David F. Penson, MD, MPH, fired off a series of letters to physician-lawmakers urging them to contact House Speaker John Boehner (R-IL) and Minority Leader Nancy Pelosi (D-CA) supporting preservation of the IOAE.

In addition, Deepak A. Kapoor, MD, president of the Large Urology Group Practice Association (LUGPA), met with Rep. Phil Roe, MD (R-TN), co-chair of the 17-member House Physicians Caucus, to emphasize the importance of the IOAE to many urologists and their patients.

“As practicing specialty physicians who treat patients with multiple complex conditions, we are concerned about the impact altering the IOAE could have on the quality of patient care, including delayed or missed diagnosis, as well as promote fragmented care,” said the AUA letter to Rep. Donna M. Christensen, MD (D-VI) and Rep. Raul Ruiz, MD (D-CA).

Following those initiatives, members of the caucus sent a letter to the House leadership pointing out that “ancillary services are used on a daily basis by physician practices to provide comprehensive services to patients,” which “facilitates the development of coordinated clinical pathways, improves communication between specialties, offers better quality control of ancillary services, and enhances data collection.”

That letter was applauded by LUGPA, the American Association of Clinical Urologists, and the AUA, which in its letter to lawmakers, noted that urologists are specialists who treat patients with multiple complex conditions. “We are concerned about the impact altering the IOAE could have on the quality of patient care, including delayed or missed diagnosis, as well as promote fragmented care.”

Efforts to tighten the exception to the Stark law’s self-referral provisions may have gained some traction as Washington seeks ways to cut the federal deficit without increasing taxes. The exception generally allows medical practices to provide designated health services, including advanced imaging services, without violating the law.

GAO, commission allege overutilization

However, calls for restricting the IOAE have come from both the U.S. Government Accountability Office (GAO) and 2010 fiscal commission chairmen Erskine Bowles and Alan Simpson over the past several months, saying it has led to overutilization of advanced imaging services by multi-millions of dollars.

In fact, GAO’s analysis, reported Sept. 28, 2012, showed that in 2010, providers who self-referred “likely made 400,000 more referrals for advanced imaging services than they would have if they were not self-referring.” GAO said those referrals cost Medicare more than $100 million in 2010 alone.

“To the extent that these additional referrals were unnecessary, they pose unacceptable risks for beneficiaries, particularly in the case of CT services, which involve the use of ionizing radiation that has been linked to an increased risk of developing cancer,” GAO said.

The government’s watchdog agency projected that Medicare Part B expenditures, which include payment for advanced imaging services, are expected to continue growing at “an unsustainable rate.” It noted that questions have been raised “about self-referral’s role in this growth,” and among its recommendations said the Centers for Medicare & Medicaid Servicers (CMS) should determine and implement a payment reduction for self-referred advanced imaging services “to recognize efficiencies when the same provider refers and performs a service.”

GAO also said CMS should “determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring physicians.”

Meanwhile, Bowles and Simpson released their final report, suggesting that the IOAE exception be limited. The report says, “Physician self-referrals should be further restricted and better monitored, including narrowing the ‘ancillary service exception.’ ”

Study adds fuel to fire

Additional ammunition for curtailing the exception may have been provided by a report from the University of Michigan Comprehensive Cancer Center, Ann Arbor, which concluded the use of advanced treatments, specifically intensity-modulated radiation therapy (IMRT) and robotic prostatectomy, in patients with low-risk prostate cancer has increased significantly despite little evidence of benefit.

The American Society for Radiation Oncology, which has been a stalwart opponent of the exception, quickly said those findings provide further proof of self-referral abuses.

The AUA, of course, disagrees and continues to battle to retain the exception. Dr. Penson urged lawmakers to co-sign a letter from Rep. Phil Roe, MD (R-TN), asking the leadership not to entertain proposals to eliminate it. Dr. Roe voted against the Patient Protection and Affordable Care Act and has sponsored legislation to repeal the Independent Payment Advisory Board, which he warns will “function as a denial-of-care board that will slash Medicare payments just to meet an arbitrary budget.”

In his letter to lawmakers, Dr. Penson said there are no data establishing a firm link between in-office ancillaries and physician overutilization.

“Limiting the tests and services that qualify for the IOAE undermines a physician’s medical judgment and has the potential to create serious, unintended consequences, including jeopardizing patient care,” he wrote.

Dr. Penson pointed out that CMS has acknowledged that one of Congress’ main objectives was to “permit the provision of in-office ancillary services for the convenience of patients during their patient visits.” Compliance with follow-up tests falls off dramatically when a patient needs to schedule them with a second medical provider, he added, suggesting that higher Medicare costs could actually result from this “non-compliance alone.”

He also said that changing the IOAE would “impede the integration of services provided in multi-specialty practices and state-of-the-art comprehensive treatment centers”-a collaborative approach that Dr. Penson said provides a patient the ability to discuss all potential options with specialists who will work together on a unified treatment plan.

“Otherwise,” he said, “a patient armed with referrals to separate specialists may be left discussing various options individually with physicians and then left to decide, among what might be conflicting advice, the best treatment option."UT

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