When Does the Business of Medicine Collide With Patient Best Interest?
The choice to go into medicine is determined by many factors, including a desire to help humanity. “Above all do no harm,” a universal principle, helps idealistic physicians deal with the fact that sometimes their best efforts to improve or save lives fail; it is consoling to know that at the very least, they did not knowingly overtreat or undertreat the patient, to that person’s detriment. Patients need to trust that their doctors’ decisions are not compromised by financial incentives or need.
Last year, the distinguished New England Journal of Medicine published a study by Jean Mitchell, “Urologists’ Use of Intensity-Modulated Radiation Therapy for Prostate Cancer,” that put referring urologists on the defensive.[i] Ms. Mitchell is well qualified to analyze the financial data. She is a Ph.D economist and professor at the McCourt School of Public Policy at Georgetown University. She analyzed treatment patterns by urologists before and after they became vested owners in IMRT services, and to compare them with non-self-referring urologists, the National Comprehensive Cancer Network (also non-self-referring urologists) and others. Her results gained dramatic attention in national news media.
A summary of her findings was published by the American Society for Radiation Oncology (ASTRO) on their website:
- “IMRT utilization among self-referring groups increased from 13.1 percent to 32.3 percent once they became self-referrers, an increase of 19.2 percentage points (146 percent). In contrast, IMRT utilization by non-self-referring urologists who were peers practicing in the same community-based setting was virtually unchanged—with a modest increase of 1.3 percentage points. Therefore, the difference-in-differences analysis reveals that self-referral accounts for 93 percent of the growth in IMRT.
- In addition to increased IMRT utilization, the data demonstrate decreases in utilization of other effective, less expensive treatment options by self-referring urologists. For example, brachytherapy decreased by 14.9 percentage points to just 2.7 percent of patients receiving this treatment in self-referring urology practices. These results are in stark contrast to non-self-referring urologists, for whom the study reports ‘virtually no change in practice patterns.’ “ [ii]
Three years prior to the NEJM article, the Wall Street Journal investigated the economic incentives behind physician use of IMRT for prostate cancer, and the impact on Medicare and other healthcare costs. According to the article, the Medicare approval for IMRT reimbursement coincided with the loss of supplemental income for urologists who were prescribing Lupron, a drug to delay prostate cancer progression, produced by TAPPharmaceutical Products. In fact, the manufacturer’s discounting practices were in violation of Federal law, and they discountined such practices (in addition to paying a hefty fine). What then happened? “IMRT emerged as the perfect income substitute, says Mark Harrison, a radiation oncologist based in McAllen, Texas, who first had the idea of integrating IMRT into a urology practice.”[iii]
The 2010 WSJ article compared Medicare payment levels for three treatments: IMRT ($40,000), radical prostatectomy ($16,000), and brachytherapy ($19,000). The article also pointed out that Watchful Waiting involved only the cost of regular office visits and testing on monitoring for cancer growth. It’s obvious that questionable, if not completely needless, overuse of IMRT puts an enormous burden on healthcare expenses.
ASTRO Chairman Colleen A.F. Lawton, MD, FASTRO, perhaps best articulates the ethics-based concern among the clinical community. She said, “Dr. Mitchell’s study provides clear, indisputable evidence that many men are receiving unnecessary radiation therapy for their prostate cancer due to self-referral. While I am a prostate cancer specialist impassioned to eradicating the disease, I am equally dedicated to utilizing these powerful technologies prudently and in the best interest of each individual patient. We must end physician self-referral for radiation therapy and protect patients from this type of abuse.”[iv]
All physicians must be on guard, ever scrutinizing our own practice to make sure that we take to heart, first and foremost, our patients’ best interests. In addition, we must examine our business arrangements to ensure that we are contributing to the financial well-being of the entire healthcare system.
[i] Mitchell JM. Urologists’ use of intensity-modulated radiation therapy for prostate cancer. N Engl J Med 2013 Oct24;369(17):1629-37.
[iii] Carreyrou J & Tamman M. “A Device to Kill Cancer, Lift Revenue.” Wall Street Journal. Dec. 7, 2010. Online at http://online.wsj.com/article/SB10001424052748703904804575631222900534954.html#printMode