Where did your urologist send you to get radiation therapy?

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!

4 Responses

  1. I think I will send a copy of this paper to CMS and several payers as this is just one of the many things causing excess health care costs.

    Why should a patient have to travel farther to receive treatment than necessary? The only ethical reason would be because the care received close by is inferior. Do the urology practices owning their own radiation equipment have data proving that is the case? If not, integrative care is not a valid argument for the extra travel; it is about making more profit pure and simple. Even more alarming is the major shift that has occurred away from brachytherapy to IMRT. The best information available shows that brachytherapy has fewer side effects and no worse efficacy for low-risk disease; it is clearly more convenient for patients and less costly for payers. Why the decline? Profit for doctors, as there is much less revenue. Something is really wrong here!

  2. As an intermediate-risk patient, I consulted with several medical/radiation oncologists and urologists representing four different small-to-large volume treatment providers. They seemed very altruistic to me in that they cordially facilitated consultation referrals to other institutions even though each had access to identical external beam linear accelerator hardware or surgical robotic equipment.

    The thoughtful UCSF radiation oncologist I consulted went so far as to suggest it would be much more convenient and equally beneficial for me to get treated locally with less than an 10-mile daily commute than endure a 100- to 300-mile daily round-trip to either Sacramento or San Francisco.

    I followed this advice and opted for local treatment. My treatment radiation oncologist turned out to be one of the pioneers in EBRT/IMRT treatment and I suspect I likely received more individualized care and closer patient coordination than I would have at the high-volume but distant facilities I could have chosen.

    It’s not always about money!

  3. RobC:

    Its nice to hear you had such a great experience.

    The difference with your story is that you were treated at an academic center. Like Kaiser physicians, academic physicians generally don’t have a financial benefit based on the treatment you choose. Private practice urologists, on the other hand, who “own” their own radiaton centers make five to six times more if you get radiation rather than surgery. Further, they can see patients in their office for the 3 hours it would have taken them to do your surgery and make (you guessed it) more money. Take a look at the numbers. … Typically one third of patients with prostate cancer get surgery, one third external radiation, and one third brachytherapy. After the urology-owned radiation centers open in a specific area, the numbers swing drastically away from surgery. And in case you’re wondering … there are no data to suggest radiation is more effective or safer. The decision is made based on patient preference. Now that physician preference is also playing into the decision-making, we are seeing a swing towards the very expensive radiation therapy.

  4. There are some statements in the comment immediately above that appear to be of — at best — dubious accuracy, as follows:

    (1) I am not aware of any good evidence to suggest that treatment of men with localized prostate cancer was ever split equally between surgery, external beam radiation therapy, and brachytherapy. Indeed, the evidence I am aware of suggests that no more than 20% of patients with localized disease have ever been treated with brachytherapy in any one year.

    (2) There is at least some good evidence to suggest that surgery is more effective at eliminating localized prostate cancer than external beam radiation therapy or brachytherapy, but that (of the three) brachytherapy has the lowest risk for adverse side effects and surgery the highest. Of course one also has to remember that many men getting treatment for low-risk, localized disease might have done just as well on some form of active monitoring and may never have needed treatment at all.

    (3) The financial benefits to a clinical practice from treating men with radiation therapy (using IMRT) as compared to surgery are notable. However, the idea that it is always five to six times higher is certainly open to question. That would depend on who the payor was and where the money was being distributed. In the case of surgery, there is a fee for the surgery and then there are the costs associated with the operating room, anesthesiology, perhaps 24-48 hours of hospitalization, etc. However, the surgeon has minimal overhead cost related to equipment (because that is largely owned by the hospital where he operates). A practice that has invested $2 million in modern IMRT equipment is paying for that equipment over time, as well as for its maintenance, and for the costs of hiring the radiation oncologist and the associated radiation physics and nursing staff to run it.

    The most recent number we saw for Medicare reimbursement for standard IMRT was $4,000 for carrying out a radical prostatectomy (exclusive of what gets paid to the hospital and other associated staff).

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