Urologists resist push to end radiology self-referrals

May 17, 2011|By Jay Hancock

There is little question that Maryland legislators intended to "substantially restrict" the ability of urologists and other prescribing doctors to refer patients to their own radiation centers, the state Court of Appeals wrote a few months ago.

Why? Study after study shows that when doctors profit from expensive radiology procedures, they order too many of them. Medicos who refer cancer patients to self-owned radiation centers "increase the use of services and costs substantially" and don't improve care, according to research published in the New England Journal of Medicine in the 1990s.

But the docs at Chesapeake Urology are still sending prostate-cancer patients to their Owings Mills radiation clinic, despite Maryland's 1993 law restricting self-referrals, despite the Court of Appeals' January decision to uphold the law and despite their failure to get legislators to exempt them from the law.

Considering the legal bills they're running up trying to keep it open, you could be pardoned for concluding that the place is a money machine.

Chesapeake Urology's Prostate Center may be the last radiation facility standing to be owned by prescribing Maryland doctors after years of regulatory rulings and litigation.

Orthopedists are selling off their MRI machines now that the state's high court has ruled that the devices can be owned only by radiologists, hospitals or others who don't order MRI scans. Prescribing doctors have to unload their CT scanners, too.

Separating the people ordering radiology procedures from the people profiting from the procedures, the thinking goes, eliminates incentives to prescribe unnecessary procedures, run up the bill and inflate medical costs.

But it's business as usual at Chesapeake Urology's Prostate Center.

The practice is in full compliance with the law, says its lawyer, Howard R. Rubin. It's unaware of any self-referral investigation by the Maryland Board of Physicians, and it hasn't been ordered to stop sending patients to its Prostate Center, he said.

The Maryland Radiological Society disagrees, saying the rules prohibit self-referral for Chesapeake Urology's radiation therapy just as they do for MRI and CT scans.

"The law is the law," says Dr. Albert Blumberg, a radiologist at Greater Baltimore Medical Center and the society's soon-to-be president. "Self-referral is not allowed in our state for three radiologic services: CT, MRI and radiation therapy."

Chesapeake Urology "is delivering the highest-quality care to patients with prostate cancer," says Rubin. He blames Blumberg's opposition on the fact that radiologists are Chesapeake Urology's business competitors. (That's true, but radiologists don't have incentives to inflate the bill because they don't order the procedures.)

Chesapeake Urology's Prostate Center delivers intensity-modulated radiation therapy, or IMRT, an option that many agree is a medical advance but one that can cost Medicare tens of thousands of dollars per patient. That's far more than the cost of prostate surgery or the increasingly favored option of "watchful waiting" for older patients to see how slow-growing tumors develop.

The huge expense for IMRT gets passed to you via taxes or insurance premiums. It's another reason the government reported last week that Medicare will face a financial crisis sooner than expected.

Chesapeake Urology is the state's biggest urology practice and the only one with its own IMRT accelerator. At least 37 urology groups nationwide own the machines, The Wall Street Journal reported last year, in an arrangement that has come under increasing criticism because of the self-referral problem.

Rubin declined to explain why Chesapeake Urology's Prostate Center's self-referral is allowed while the board ruled that those for MRIs and CTs are not, saying he didn't want to have a legal debate in the newspaper.

But if the urologists' legal ground is so solid, why did they ask this year's General Assembly to exempt radiation therapy along with MRIs and CTs from the law prohibiting doctor self-referral? That bill failed, which is why the orthopods are so busy unloading their MRI machines.

Both Dr. Joshua M. Sharfstein, the state's secretary of health and mental hygiene, and the Board of Physicians declined to discuss specific investigations regarding alleged self-referral violations.

"The evidence is pretty clear that self-referral is associated with increased costs without a demonstrable increase in quality per patient," Sharfstein said in an interview.

Rather than setting a hard deadline for ending self-referral deals for radiation therapy, as it did for MRIs and CTs, the board wrote vaguely that it will "proceed with the investigation of complaints" about such arrangements. Expect lawyer bills to grow.

But if you're a cancer patient at Chesapeake Urology, you should know that its professionals operate under incentives that are substantially different from those of doctors without a financial stake in your therapy. If they want to zap you at their prostate center, get a second opinion about whether that's really the best option.

And if you're a taxpayer or health-insurance customer, check your wallet.


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