The self-referral debate: Give us some truth

The ongoing argument about the issue of self-referral continued this week with the publication of a study in the New England Journal of Medicine that found that urology groups that self-refer intensity-modulate radiation therapy (IMRT) are much more likely to recommend it than their colleagues who don't self-refer.

The results of the study inspired standard responses from organizations that have long had a dog in this fight, such as the American Society for Radiation Oncology (ASTRO), which has long argued for the elimination of the in-office Ancillary Services Exception (IOAS) to the Stark Law allowing self-referral exemptions for services such as advanced imaging and radiation therapy; and urology associations, which strongly support maintaining those self-referral exceptions.

It is certainly understandable why physician groups like the American Urological Association (AUA) continue to support the IOAS exception--eliminating it would have a significant financial impact on those physicians that have invested in these ancillary services.

But can't we have a discussion about this important healthcare policy question that is intellectually honest?

The New England Journal of Medicine study was conducted by Jean Mitchell, Ph.D., of Georgetown University, and was sponsored by ASTRO. In a statement blasting her study, the AUA charged that Mitchell's selection of control groups may not be representative of general practice trends and that "one cannot help but wonder whether Dr. Mitchell chose the control groups to arrive at results that were acceptable to the study's sponsors."

As Mitchell acknowledges, her research was "supported by an unrestricted educational research contract between the American Society for Radiation Oncology and Georgetown University." But, beyond that, the AUA is implying that her services have been bought and paid for by ASTRO and that she is tailoring her findings to that end. How does this kind of charge help further a civil discussion of the issue?

In its statement the AUA goes on to point out that the General Accountability Office (GAO) recently issued a series of reports on self-referral and "flatly rejected the recommendation to limit the Stark exception."

Here the AUA interpretation of the GAO's position--referenced in the GAO report, "Higher Use of Costly Prostate Cancer Treatment by Providers Who Self-Refer Warrants Scrutiny" —is suspect, to say the least. Yes, the GAO was asked by ASTRO to recommend limits to the Stark exception. And, yes, it failed to do so--but only because, as it stated in the report, an "examination of the IOAS was beyond the scope of our work."

What the AUA neglects to mention is that in the report the GAO found that providers that self-refer IMRT services were substantially more likely to refer their prostate cancer patients for IMRT and less likely to refer them for other, less costly, treatments.  Furthermore, the GAO asserted, "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."

This is a healthcare policy question with significant implications for patient care and how we pay for that care. This is not some political campaign where we expect the truth to be handled a little carelessly. Is it too much to ask for a little more in the way of intelligent discourse about such an important issue? - Mike  @FierceHealthIT

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