Pathology, IMRT studies heat up self-referral debate for urologists

National Report-Urologists have just been hit with a solid left-right combination in a new round of the fight over self-referral. Within a month, they have had to counter two separate studies questioning their use of in-house pathology and radiology services. And although they may be winning on points with their scientific arguments, that edge could be lost on a referee and crowd who are wowed by the opponents' impressive footwork.

First came an article in Health Affairs by Jean Mitchell, PhD, of Georgetown University, Washington, supported by an unrestricted contract from the American Clinical Laboratory Association (ACLA) in conjunction with the College of American Pathologists (CAP). That study found that self-referring urology practices billed Medicare more for prostate biopsy samples than did non-self-referring urologists, all while detecting fewer cases of cancer (Health Aff 2012; 31:741-9). Dr. Mitchell concluded that lower cancer detection rates linked to self-referring urologists suggest that financial incentives prompt those urologists to perform prostate biopsies on marginal cases and that "the findings support eliminating the exception that permits physicians to self-refer patients to in-office pathology laboratories."

In a second study in the same issue of Health Affairs, researchers reported that men with low-risk prostate cancer were almost as likely as high-risk patients to receive intensity-modulated radiotherapy (IMRT) treatments (Health Aff 2012; 31:750-9). The authors, led by urologist Brent K. Hollenbeck, MD, MS, of the University of Michigan, Ann Arbor, expressed concern about overtreatment and higher health care costs, and a subsequent press release from the American Society of Radiation Oncologists (ASTRO) blamed the problem on self-referring urologists.

"It is not strong science," Dr. Penson said of the Dr. Mitchell study.

Dr. Penson and Steven M. Schlossberg, MD, MBA, who heads the AUA Health Policy Council, took apart Dr. Mitchell's findings on lower cancer detection rates. They also raised doubts about the validity of the data used in her study.

"This is just a money grab on the part of pathology," said Dr. Penson, professor of urologic surgery at Vanderbilt University, Nashville, TN. "You would think they would spend their research dollars on things that would help patients, like identifying pathologic tissue markers for indolent prostate cancer, as opposed to using these funds to maintain their personal revenue streams."

"To suggest that certain practices are performing extra and unnecessary pathology work for their own remuneration when they are working within rational clinical guidelines is offensive," said Dr. Kapoor, chairman and CEO of Integrated Medical Professionals in greater New York.

In addition, Dr. Penson said the IMRT study contained no data on ownership of the radiology facilities in question and that it failed to show whether ownership was driving the issues of higher costs and possible overtreatment.