Medicare fee reductions and the overuse of intensity-modulated radiotherapy.

OBJECTIVE: To estimate the impact of a large Medicare fee reduction for intensity-modulated radiation therapy (IMRT) on its use in prostate and breast cancer patients. DATA SOURCES/STUDY SETTING: SEER-Medicare. STUDY DESIGN: We compared trends in the use of IMRT between patients treated in practices directly affected by fee reductions (for prostate cancer, men treated in urology practices that own IMRT equipment; for breast cancer, women treated in freestanding radiotherapy clinics) and patients treated in other types of practices. DATA COLLECTION/EXTRACTION METHODS: We identified breast and prostate cancer patients receiving IMRT using outpatient and physician office claims. We classified urology practices based on whether they billed for IMRT and radiotherapy clinics based on whether they were reimbursed under the Physician Fee Schedule. PRINCIPAL FINDINGS: Between 2006 and 2015 the payment for IMRT delivered in freestanding clinics and physician offices declined by $367 (-54.7%). However, the use of IMRT increased in physician practices subject to payment cuts, both in absolute terms and relative to use in practices unaffected by the payment cut. Use of IMRT in prostate cancer patients treated at urology practices that own IMRT equipment increased by 9.1 (95% CI: 2.0-16.2) percentage points between 2005 and 2016 relative to use in patients treated at other urology practices. Use of IMRT in breast cancer patients treated at freestanding radiotherapy centers increased by 7.5 (95% CI: -5.1 to 20.1) percentage points relative to use in patients treated at hospital-based centers. CONCLUSIONS: A steep decline in IMRT fees did not decrease IMRT use over the period from 2006 to 2015, though use has declined since 2010.

Ultrasound self-referral does not increase utilization in pediatric urology.

INTRODUCTION: Costs of radiologic imaging are rising. The goal of this study is to examine the utilization practices of pediatric urologists who have access to in-office ultrasound imaging when managing children with primary hydronephrosis. MATERIALS AND METHODS: A retrospective cross sectional study was performed of children ≤ 5 years old with an isolated diagnosis of hydronephrosis. Ultrasound utilization was evaluated by tallying the number of ultrasounds obtained during the time each child was followed. Imaging frequency was determined from orders given by each overseeing physician. Ultrasounds were performed at either the practitioner's clinic or at outside radiology facilities based on insurance regulations. Analysis compared ordering frequency between imaging completed at the clinic versus outside radiology facilities. RESULTS: Of 1,816 ultrasounds ordered, 1,102 were performed at the practitioner's clinic and 714 at outside radiology centers. Overall, the number of ultrasounds obtained in the practitioner's clinic was 0.33 ultrasound studies per patient per month, in contrast to 0.38 obtained in outside radiology settings. Ultrasound utilization for low, intermediate and high grades of hydronephrosis in practitioner's clinic versus outside was 0.39 versus 0.31, 0.31 versus 0.31, and 0.37 versus 0.39 respectively. There were no significant differences in ultrasound ordering frequency for all groups compared. CONCLUSIONS: There is no increase in ultrasound utilization for managing primary hydronephrosis in children, regardless of whether the study was self or outside referral. Honest and ethical utilization of self-owned radiologic equipment is possible and allows for timing monitoring, physician and patient convenience, and potential cost savings.

Patient and care characteristics of self-referrals treated by the general practitioner cooperative at emergency-care-access-points in the Netherlands.

BACKGROUND: In the Netherlands, out-of-hours primary care is provided in general practitioner-cooperatives (GPCs). These are increasingly located on site and in collaboration with emergency departments of hospitals (ED). At such sites, also called emergency-care-access-points (ECAP), the GPC is generally responsible for the triage and treatment of self-referrals who used to attend the ED. To evaluate the effects and safety of this novel organisation, we studied the characteristics and the quality of care given by GPCs to self-referrals at ECAPs. METHODS: Retrospective analysis (August 2011-January 2012) of 783 records of self-referred patients at three Dutch GPCs in an ECAP. This was supplemented with a retrospective analysis of patient records during a follow-up period of three-months to asses safety. RESULTS: Patient-characteristics: 59% was male, 46% aged between 16-45 years and 59% trauma-related. Most cases (95%) were triaged low-urgent. None received the highest urgency-category. Quality: The triage outcome was correct in 79%, underestimated in 12% and overestimated in 9%. After GP consultation 20% were referred to the ED, mostly for radio-diagnostics. Of the referrals to secondary care, 98% were according to common medical practice. Thirty percent had a follow-up contact, mostly with their own general practitioner, seldom with the ED. Complications, all non-severe, were registered in 3.2%; 0.4% were possibly preventable. CONCLUSIONS: Self-referred patients at an ECAP are mostly trauma related, low-urgent and male patients. The majority could be treated by the GPC without subsequent referral to the ED. Care given at the GPC is reasonably efficient and safe. Triage and treatment of self-referrals by the GPC at ECAPs might offer opportunities for other countries facing problems with inappropriate emergency department visits.

Gatekeeping and the utilization of physician services in France: Evidence on the Médecin traitant reform.

In 2005, France implemented a gatekeeping reform designed to improve care coordination and to reduce utilization of specialists' services. Under this policy, patients designate a médecin traitant, typically a general practitioner, who will be their first point of contact during an episode of care and who will provide referrals to specialists. A key element of the policy is that patients who self-refer to a specialist face higher cost sharing than if they received a referral from their médecin traitant. We consider the effect of this policy on the utilization of physician services. Our analysis of administrative claims data spanning the years 2000-2008 indicates that visits to specialists, which were increasing in the years prior to the implementation of the reform, fell after the policy was in place. Additional evidence from the administrative claims as well as survey data suggest that this decline arose from a reduction in self-referrals, which is consistent with the objectives of the policy. Visits fell significantly both for specialties targeted by the policy and specialties for which self-referrals are still allowed for certain treatments. This apparent spillover effect may suggest that, at least initially, patients did not understand the subtleties of the policy.

Effect of Direct Marketing for Uterine Artery Embolization on Rates of Leiomyomas, Incidental Findings, and Management After Pelvic MRI.

PURPOSE: The aim of this study was to determine whether a self-referred population screened by an interventional radiology (IR) clinic and a non-IR, physician-referred population differed with regard to suitability for uterine artery embolization (UAE) for symptomatic leiomyomas on the basis of preprocedure MRI. METHODS: This was an institutional review board-approved, HIPAA-compliant retrospective study of 301 women evaluated in an IR clinic for possible UAE from January 2009 to September 2012. Subjects were retrospectively divided into two groups: self-referred via direct marketing (group A, n = 203; mean age, 41.8 years; range, 22-58 years) and physician referred (group B, n = 98; mean age, 42.9 years; range, 30-65 years). RESULTS: There was no significant difference between groups in presenting symptoms (multiple symptoms, bleeding, bulk-related symptoms, pain). After initial screening, 73.4% of group A (149 of 203) and 79.6% of group B (78 of 98) underwent MRI (P = .242). On the basis of MRI findings, 91.3% of group A (136 of 149) and 94.9% of group B (74 of 78) had uterine leiomyomas (P = .328). Adenomyosis without leiomyoma was present in 4.0% of group A (6 of 149) and 3.8% of group B (3 of 78) (P = .947). Incidental findings requiring further clinical or imaging evaluation were found in 20.8% of group A (31 of 149) and 24.4% of group B (19 of 78) (P = .539). After MRI, 41.6% of group A (62 of 149) and 48.7% of group B (38 of 78) proceeded to UAE (P = .306). CONCLUSIONS: After initial screening, similar proportions of self-referred and physician-referred patients were candidates for UAE. The rates of confirmed leiomyomas and incidental findings on MRI were similar between groups.

Anticipating the Unintended Consequences of Closing the Door on Physician Self-Referral.

PURPOSE: While physician self-referral has been associated with increased health care use, the downstream effects of the practice remain poorly characterized. Accordingly we identified the relationship between urologist self-referral and downstream health care use in patients with urinary stone disease. MATERIALS AND METHODS: With urologist self-referral status as the exposure of interest, we performed a retrospective cohort study of Medicare beneficiaries from 2008 to 2010 to evaluate the relationship between self-referral and imaging intensity, risk of surgical treatment and time to surgical treatment for urinary stone disease. RESULTS: We identified dose dependent increases in computerized tomography use with increasing stratum of urologist self-referral. Compared to nonself-referring urologists, computerized tomography use was 1.19 times higher (95% CI 1.07-1.34) in episodes ascribed to intermediate frequency (5 to 9) and 1.32 times higher (95% CI 1.16-1.50) in episodes ascribed to high frequency (10+) self-referring urologists. Self-referral was inversely associated with risk of surgical treatment for stone disease. Specifically, patients treated by intermediate and high frequency self-referring urologists were less likely to undergo surgical treatment than those treated by nonself-referring urologists, with HR 0.84 (95% CI 0.71-0.99) and HR 0.81 (95% CI 0.66-0.99), respectively. We identified no statistically significant between-group differences in time to surgical treatment. CONCLUSIONS: Self-referral is associated with increased use of computerized tomography and with decreased use of surgery for stone disease. While policy efforts to further restrict physician self-referral may reduce the use of computerized tomography, they may also result in unintended consequences with respect to patterns of surgical care.

Self-referrals in a Dutch Emergency Department: how appropriate are they?

OBJECTIVE: Self-referred visits account for an average of 30% of all Emergency Department (ED) visits in the Netherlands. Some of these are considered inappropriate, because patients receive care that a GP can provide. Worldwide, studies have used various methods to determine the proportion of inappropriate visits by self-referred patients, resulting in diverging percentages. The aim of this study was to find a reliable percentage of appropriate visits to the ED by self-referred patients in the Netherlands. METHODS: This observational, prospective study was performed in the ED of a hospital in the Netherlands. Data were collected on all self-referred patients in four separate months over 1 year. The appropriateness of an ED visit was determined at two time points: first, after primary assessment of the patient, using predefined criteria, and second the moment the patient left the ED, on the basis of the diagnosis and treatment received. Finally, the perspective of the patients was taken into account using a questionnaire. RESULTS: In 4 months 3196 self-referred patients were included. In all, 1862 (58.8%) visits were classified as appropriate according to the predefined criteria. When the second time point was taken into consideration, 48.1% of the patients had a secondary care diagnosis and/or needed secondary care treatment, classifying their visits as appropriate. According to the opinion of the patients 76.7% classified their visit as appropriate. CONCLUSION: The percentage of appropriate ED visits by self-referred patients in the Netherlands ranges from 48.1 to 58.8%, as determined using two different methods.

Physician self-referral and imaging use appropriateness: negative cervical spine MRI frequency as an assessment metric.

BACKGROUND AND PURPOSE: Imaging self-referral is increasingly cited as a contributor to diagnostic imaging overuse. The purpose of this study was to determine whether ownership of MR imaging equipment by ordering physicians influences the frequency of negative cervical spine MR imaging findings. MATERIALS AND METHODS: A retrospective review was performed of 500 consecutive cervical spine MRIs ordered by 2 separate referring-physician groups serving the same geographic community. The first group owned the scanners used and received technical fees for their use, while the second group did not. Final reports were reviewed, and for each group, the percentage of negative study findings and the frequency of abnormalities were calculated. The number of concomitant shoulder MRIs was recorded. RESULTS: Five hundred MRIs meeting inclusion criteria were reviewed (250 with financial interest, 250 with no financial interest). Three hundred fifty-two had negative findings (190 with financial interest, 162 with no financial interest); there were 17.3% more scans with negative findings in the financial interest group (P = .006). Among scans with positive findings, there was no significant difference in the mean number of lesions per scan, controlled for age (1.90 with financial interest, 2.19 with no financial interest; P = .23). Patients in the financial interest group were more likely to undergo concomitant shoulder MR imaging (24 with financial interest, 11 with no financial interest; P = .02). CONCLUSIONS: Cervical spine MRIs referred by physicians with a financial interest in the imaging equipment used were significantly more likely to have negative findings. There was otherwise a highly similar distribution and severity of disease between the 2 patient samples. Patients in the financial interest group were more likely to undergo concomitant shoulder MR imaging.

Urologists' use of intensity-modulated radiation therapy for prostate cancer.

BACKGROUND: Some urology groups have integrated intensity-modulated radiation therapy (IMRT), a radiation treatment with a high reimbursement rate, into their practice. This is permitted by the exception for in-office ancillary services in the federal prohibition against self-referral. I examined the association between ownership of IMRT services and use of IMRT to treat prostate cancer. METHODS: Using Medicare claims from 2005 through 2010, I constructed two samples: one comprising 35 self-referring urology groups in private practice and a matched control group comprising 35 non-self-referring urology groups in private practice, and the other comprising non-self-referring urologists employed at 11 National Comprehensive Cancer Network centers matched with 11 self-referring urology groups in private practice. I compared the use of IMRT in the periods before and during ownership and used a difference-in-differences analysis to evaluate changes in IMRT use according to self-referral status. RESULTS: The rate of IMRT use by self-referring urologists in private practice increased from 13.1 to 32.3%, an increase of 19.2 percentage points (P<0.001). Among non-self-referring urologists, the rate of IMRT use increased from 14.3 to 15.6%, an increase of 1.3 percentage points (P=0.05). The unadjusted difference-in-differences effect was 17.9 percentage points (P<0.001). The regression-adjusted increase in IMRT use associated with self-referral was 16.4 percentage points (P<0.001). The rate of IMRT use by urologists working at National Comprehensive Cancer Network centers remained stable at 8.0% but increased by 33.0 percentage points among the 11 matched self-referring urology groups. The regression-adjusted difference-in-differences effect was 29.3 percentage points (P<0.001). CONCLUSIONS: Urologists who acquired ownership of IMRT services increased their use of IMRT substantially more than urologists who did not own such services. Allowing urologists to self-refer for IMRT may contribute to increased use of this expensive therapy. (Funded by the American Society for Radiation Oncology.).

Physician self-referral of lumbar spine MRI with comparative analysis of negative study rates as a marker of utilization appropriateness.

OBJECTIVE: Financial interest in imaging equipment may affect the imaging referral patterns of ordering physicians. The purpose of this article is to determine whether ownership of MRI equipment by ordering physicians predicts the likelihood and prevalence of positive findings on lumbar spine MRI as a metric for comparison of utilization. MATERIALS AND METHODS: A retrospective review was performed of 500 consecutive diagnostic lumbar spine MRI examinations in one radiology practice ordered by two separate referring physician groups serving the same geographic community: one with financial interest in the MRI equipment used (financial-interest group) and one without financial interest in the MRI equipment used (no-financial-interest group). Negative examinations and total number of lesions per positive study were recorded for each group. RESULTS: Five hundred scans met inclusion criteria during the study period (250 in the financial-interest group and 250 in the no-financial-interest group). The negative scan frequency was 86% higher in the financial-interest group (p < 0.0001). Among positive scans, there was no significant difference in the average total number of positive lesions per scan (3.93 for the financial-interest group and 4.31 for the no-financial-interest group; p = 0.132). The average age of patients imaged by the financial-interest group was 49.8 years, versus 56.9 years for the no-financial-interest group (p < 0.0001). CONCLUSION: Lumbar spine MRI examinations referred by the financial-interest group were significantly more likely to be negative than those referred by the no-financial-interest group. Lesion frequency among positive scans suggests similar severity of disease between the two patient populations. Patients imaged by the financial-interest group were significantly younger than those imaged by the no-financial-interest group.

Urologists' self-referral for pathology of biopsy specimens linked to increased use and lower prostate cancer detection.

Federal law allows physicians in some circumstances to refer patients for additional services to a facility in which the physician has a financial interest. The practice of physician self-referral for imaging and pathology services has been criticized because it can lead to increased use and escalating health care expenditures, with little or no benefit to patients. This study examined Medicare claims for men in a set of geographically dispersed counties to determine how the "in-office ancillary services" exception affected the use of surgical pathology services and cancer detection rates associated with prostate biopsies. I found that self-referring urologists billed Medicare for 4.3 more specimens per prostate biopsy than the adjusted mean of 6 specimens per biopsy that non-self-referring urologists sent to independent pathology providers, a difference of almost 72 percent. Additionally, the regression-adjusted cancer detection rate in 2007 was twelve percentage points higher for men treated by urologists who did not self-refer. This suggests that financial incentives prompt self-referring urologists to perform prostate biopsies on men who are unlikely to have prostate cancer. These results support closing the loophole that permits self-referral to "in-office" pathology laboratories.

Dramatically increased musculoskeletal ultrasound utilization from 2000 to 2009, especially by podiatrists in private offices.

PURPOSE: Over the past two decades, musculoskeletal (MSK) ultrasound has emerged as an effective means of diagnosing MSK pathologies. However, some insurance providers have expressed concern about increased MSK ultrasound utilization, possibly facilitated by the low cost and ready availability of ultrasound technology. The purpose of this study was to document trends in MSK ultrasound utilization from 2000 to 2009 within the Medicare population. METHODS: Source data were obtained from the CMS Physician/Supplier Procedure Summary Master Files from 2000 to 2009, and records were extracted for procedures for extremity nonvascular ultrasound. We analyzed annual volume by provider type using specialties, practice settings, and geographic regions where the studies were performed. RESULTS: In 2000, Medicare reimbursed 56,254 MSK ultrasound studies, which increased to 233,964 in 2009 (+316%). Radiologists performed the largest number of MSK ultrasound studies in 2009, 91,022, an increase from 40,877 in 2000. Podiatrists utilized the next highest number of studies in 2009, 76,332, an increase from 3,920 in 2000. Overall, private office MSK ultrasound procedures increased from 19,372 in 2000 to 158,351 in 2009 (+717%). In 2009, podiatrists performed the largest number of private office procedures (75,544) and accounted for 51.5% of the total private office growth from 2000 to 2009. Radiologist private office procedures totaled 19,894 in 2009, accounting for 9.2% of the total private office MSK ultrasound growth. CONCLUSIONS: The MSK ultrasound volume increase among nonradiologists, especially podiatrists, was far higher than that among radiologists from 2000 and 2009, with the highest growth in private offices. These findings raise concern for self-referral.