Four years ago, doctors at Chesapeake Urology Associates started ordering the most expensive kind of prostate-cancer therapy for many more of their patients.
Before 2007, the large, multi-office practice was prescribing the treatment, known as intensity modulated radiation therapy, for 12 percent of its prostate-cancer patients covered by Medicare, according to data compiled by a Georgetown University researcher. But starting in mid-2007, Chesapeake Urology's referral rate for IMRT more than tripled, rising to 43 percent of the Medicare cases.
What could have caused such a sharp change?
It couldn't have been because IMRT, which costs about $40,000 per treatment, was new. Maryland hospitals had been offering it for years.
It couldn't have been because IMRT was better.
"No randomized clinical trials show that prostate cancer patients receiving IMRT live longer or experience fewer long-term side effects than those getting the alternatives" of radiation-seed therapy or surgery, said Dr. James Mohler, a urologist at Roswell Park Cancer Institute in Buffalo, N.Y., and chairman of the national committee that sets standards for prostate-cancer care.
Chesapeake Urology tripled its percentage of prescriptions for IMRT after the practice acquired its own IMRT machine in 2007. The more patients the Baltimore-area urologists referred for that expensive therapy alternative, the more revenue and profits they would generate.
"They're steering patients to IMRT because that's where they make their money," said Jean Mitchell, a professor and health care economist at Georgetown who's working on a national study about IMRT referrals. "They're making a ton of money out of this. There's no question about it. At the expense of the taxpayers" who finance Medicare.
Through its lawyer, Chesapeake Urology said its only desire is to practice the best medicine.
"CUA's doctors are well-respected physicians of the highest integrity," said Howard R. Rubin, the attorney. "They reject any insinuation by you or Prof. Mitchell that any recommendations relating to a patient's care are motivated by anything other than the best interests of the patient."
In any event, the Medicare data put Chesapeake Urology at the center of the debate over "self-referral" — when prescribing doctors have a financial stake in patients' treatment. Many authorities believe self-referral for expensive tests and treatment inflates medical costs and places the profit motive above what's best for the patient.
As an academic, Mitchell can obtain vast Medicare billing records that are unavailable to the public. She's preparing a paper she says will show that urology practices across the country drastically increase expensive IMRT referrals after they acquire a machine.
In fact, she said, the doctors at Chesapeake Urology "are some of the less egregious." Some urology practices in other states send close to 70 percent of their prostate-cancer patients to their own IMRT machines, she said.
Mitchell agreed to share her data on Chesapeake Urology with me. It should be noted that the American Society for Radiation Oncology, or ASTRO, is paying Georgetown for her research. ASTRO represents independent and hospital-based radiation oncologists who are losing business to urologists who self-refer for IMRT, so they have an interest in the conclusion.
However, ASTRO and Mitchell say the society has no control over what she publishes. And ASTRO's payments, she said, go to the university, not to her.
In any case, to dismiss the dispute as a trade war is to miss the larger point. Independent or hospital-based radiation oncologists don't have the power to inflate medical bills by ordering possibly unneeded IMRT procedures. They don't prescribe the treatment. Urologists who own IMRT accelerators do.
Recognizing this kind of problem, Congress banned most self-referral in the late 1980s and early 1990s. The idea was to separate the doctor ordering the procedure from the doctor profiting from the procedure. But there was a loophole in the federal legislation not only for radiation therapy but for diagnostic MRI scans and CT scans, which Maryland became the first state in the country to try to close.
Last year, the Court of Appeals upheld Maryland's stricter self-referral ban, forcing orthopedists and other prescribing doctors to sell off their lucrative MRI machines. Albert Blumberg, a radiation oncologist who is president of the Maryland Radiological Society, said the ruling also seems to outlaw self-referral for IMRT.
"The Maryland Radiological Society believes that Chesapeake Urology is not in compliance with our interpretation and the state Court of Appeals' interpretation of the existing Maryland statute," he said.