Study: Urologist self-referral of prostate pathology services raises usage, cost

Urologists' self-referral of prostate surgical pathology services leads to increased use and higher Medicare spending but lower cancer detection rates, according to a recent study.

Urologists’ self-referral of prostate surgical pathology services leads to increased use and higher Medicare spending but lower cancer detection rates, according to a recent study.

The study, which was published in Health Affairs (2012; 31:741-9), was authored by Jean M. Mitchell, PhD, of Georgetown University, Washington. It was supported by an unrestricted contract from the American Clinical Laboratory Association in conjunction with the College of American Pathologists.

The AUA and Large Urology Group Practice Association (LUGPA) were quick to take issue with the study.

"It is not strong science," said David F. Penson, MD, MPH, vice chair of AUA’s Health Policy Council.

In the study, Dr. Mitchell analyzed data on 36,261 biopsies performed on Medicare beneficiaries in the period 2005-‘07, with 27,334 by non-self-referring providers versus 9,927 by self-referring providers, and found that self-referring providers billed Medicare for 4.3 (about 72%) more specimens with pathology tissue cores per prostate biopsy than non-self-referring urologists sent to independent pathology providers.

Dr. Mitchell also found that the prostate cancer detection rate for men whose biopsies were performed by self-referring urologists was 8.3 percentage points lower than the rate for men treated by non-self-referring physicians in the study period.

Dr. Mitchell concludes 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."

Dr. Penson said the article completely ignores the standards of care that have been set by the pathologists themselves. Dr. Mitchell’s principal argument is that self-referring urologists limit the number of specimens per submitted jar in multiple-needle biopsies, and because Medicare reimbursement is based on the number of jars submitted, the urologists are inflating their bills. However, Dr. Penson cites authoritative pathologists such as David G. Bostwick, MD, who advises against submitting specimens together because they entangle and fragment, and other studies in the U.S. and in Europe-where the question of financial incentive is moot-that also fault submitting multiple specimens in the same container.

The bottom line, says Dr. Penson, is that self-referring urologists are following the standard of care and practicing evidence-based medicine.

"This is just a money grab on the part of pathology," said Dr. Penson, of 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."

"This study simply furthers the political agenda of its sponsors to recapture lost market share and does not deserve credible recognition," said LUGPA President Deepak A. Kapoor, MD. "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."

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