The issue of self-referral of prostate cancer patients to urologist-owned radiation therapy facilities is back in the news again as a result of an article in the September 1 issue of “The Red Journal” (the International Journal of Radiation Oncology • Biology • Physics).
In their article, Jhaveri et al. report their findings regarding the effects on patients of self-referral by urologists to urology-owned radiation therapy facilities exclusively in Texas. It should be noted immediately that the authors appear to have a clear interest in the published finding since six of the seven named authors are specialists in radiation therapy and/or radiation oncology. Readers may also want to see the media release from the American Society for Radiation Oncology (ASTRO) and the commentary on the HealthDay web site that deal with this paper. To date we have seen no comment from the urology community.
According to the paper by Jhaveri et al.:
- They were able to identify 229 urology practices in Texas.
- 12/229 urology practices identified (5 percent) offered “integrated” radiation oncology services (in other words, they were able to self-refer patients)
- 182/640 Texas-based urologists (28 percent) worked in these 12 practices.
- 53 percent of the population of Texas lives within within 10 miles of a urology practice that offers “integrated” radiation oncology services.
- Patients diagnosed with prostate cancer at a urology practice clinic that offers “integrated” radiation oncology services must travel, on average,
- 19.7 miles from the clinic to reach the radiation oncology facility owned by the integrated practice
- 5.9 miles from the clinic to reach the nearest non-integrated radiation oncology facility
Now the whole issue of self-referral of patients for any and all types of health care service is complicated and fraught with all sorts of clinical, ethical, and business-related issues. Just to give some context, if your health care is provided by an organization like the Geisinger Health System (in Pennsylvania) or Kaiser Permanente (particularly in California) “self-referral” is a common fact of life because the entire system is built around the concept of integrated care. These health care systems own nearly all of their own specialty service capabilities, and most of their physicians are employees, not independent service providers.
In the study by Jhaveri et al., we see two fundamental issues:
- The distance patients have to drive from the urology clinic where they are diagnosed to the radiation therapy facility where they may receive treatment is irrelevant. Why? Because the patients may never have to do that at all! The important question for the patient is going to be how far they have to drive from their home or their work to the radiation oncology clinic. That is the drive that they will have to take (for as many as 5 days a week for the best part of 2 months).
- The study makes no attempt to deal with the real problem, which is the quality of services being provided and the potential for financial benefit to the urology group practice.
Now, it is quite certainly the case that some of the larger urology groups have set out to “capture” every possible prostate cancer patient and to provide nearly all the services required by that patient from the time he first walks through the door with an elevated PSA or a suspicious DRE to the time that he has severe metastatic disease and clearly needs care from a medical oncologist. Arguably, there is nothing really wrong with that. By providing a complete range of highly specialized services focused on prostate cancer patients (including pathology services, surgical services, radiation oncology services, and even diagnostic radiology services), such urology groups can reasonably argue that they are seeking to provide very high quality, integrated care for a highly-defined group of patients.
It is quite understandable, however, that independent radiation oncology practitioners aren’t going to see things that way. Their perspective is that these urology groups are manipulating the system to optimize revenue and profit (not least because there is more money to be made from treating patients with radiation therapy than by treating them surgically).
The “New” Prostate Cancer InfoLink takes a very different position on this entire issue … which is that patients shouldn’t be making decisions about where to get treatment based (exclusively) on convenience. Patients should be making decisions about their care based on where they can reliably get the highest quality of care at reasonable cost and reasonable convenience (if for example one needs to have an extended period of external beam radiation therapy).
We can expect the Large Urology Group Practice Association (LUGPA) to have something to say about the paper by Jhaveri et al. in the near future. This issue will not be going away any time soon!