Prostate Cancer and Medicare Fraud

It’s tempting to become cynical about medicine when one hears reports of Medicare abuse or violations of Federal laws. These stories are especially rankling when greed appears to be the motive, and the victims are cancer patients. A few years ago, journalist Peter Waldman, writing for Bloomberg Business, assembled several anecdotes into a disturbing article about mining prostate cancer (PCa) for gold.[i]

For example, a California urologist was able to bill Medicare $30,000 for prescribing a radiation treatment that a) the patient was unsuited for and b) that a radiologist, not the referring urologist, actually delivered. An investigation is ongoing to learn if the doctors involved had violated self-referral and anti-kickback laws at taxpayers’ expense. Even worse, the patient died two years later from metastatic PCa because the cancer had already started to spread at the time of treatment.

According to the Waldman article, financial incentives are a big part of the problem, especially since the boom in radiation centers that offer Intensity Modulated Radiation Therapy (IMRT). According to radiologyinfo.org, “Intensity-modulated radiation therapy (IMRT) is an advanced mode of high-precision radiotherapy that uses computer-controlled linear accelerators to deliver precise radiation doses to a malignant tumor or specific areas within the tumor.”[ii] According to some guidelines, IMRT may be a good choice for younger PCa patients with aggressive disease – but it may be overkill for low risk PCa patients. IMRT equipment is expensive, and it originally received significantly higher Medicare reimbursement levels than traditional external beam radiation. This has changed because Medicare was concerned about financial incentives for urologists to prescribe IMRT, and has reduced the reimbursement levels in order to trim medical costs. Still, IMRT prescriptions have increased whereas brachytherapy has dropped. Prostate treatment expert Dr. Matthew Cooperberg estimates that “about half the 50,000 men who receive IMRT for prostate cancer each year don’t need it or don’t gain anything from it that exceeds cheaper treatment, resulting in about $1 billion of overspending.”[iii]

It is good to know that Medicare conducts behind-the-scenes investigations into fraudulent and conflict-of-interest abuses. Most of the time, taxpayers are unaware of what their doctors bill Medicare for, so investigative journalism like Waldman’s is important for raising awareness. When Medicare is able to hold doctors accountable for questionable business practices, unnecessary spending can be kept under control. In those cases, everyone—not just cancer patients—benefits.

 


 

[i] Peter Waldman, “Prostate Patients Suffer as Money Overwhelms Best Therapy,” Bloomberg Business, November 5, 2012. http://www.bloomberg.com/news/articles/2012-11-06/prostate-patients-suffer-as-money-overwhelms-optimal-therapy

[ii] http://www.radiologyinfo.org/en/info.cfm?pg=imrt

[iii] Peter Waldman, ibid.

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