Physicians groups want to preserve a key antitrust exemption for self-referrals under Medicare that the Obama Administration hopes to end for a number of costly services.
The American Medical Association and 30 other speciality and practice management organizations are calling on lawmakers to reject the President's proposal to remove advanced imaging, radiation therapy, anatomic pathology and physical therapy from the Stark physician referral law's "in-office ancillary services exception."
At a time when integrated and coordinated care are being used as vehicles for health reform, the AMA and its peers, including the Medical Group Management Association, argue that the Stark exception "recognizes that referral within a group practice promotes continuity of care in a setting that is lower cost and more convenient to the patient."
Limiting the IOASE, as the exception is abbreviated, "would force patients to receive ancillary services in a new and unfamiliar setting, increase inefficiencies, present significant barriers to appropriate screenings and treatments, and make health care both less accessible and less affordable," the groups wrote in a letter to the Senate Finance Committee and the House Ways and Means Committee.
White House budget experts, though, argue that while the exception may have "many appropriate uses," some services, like advanced imaging and outpatient therapy, "are rarely furnished on the same day as the related physician office visit."
And more than that, the White House argues in its budget proposal, the exception "may have resulted in overutilization and rapid growth of certain services." Ending it for advanced imaging, radiation therapy, anatomic pathology and physical therapy, the White House estimates, would save Medicare $6 billion over 10 years.
The proposal to end the exception for one large category of services -- anatomic pathology -- has also led to a split among the AMA and other professional groups.
Cheering the President's idea, the College of American Pathology argues that the exception was never appropriate for anatomic pathology in the first place and that it has had a range of unintended consequences -- notably in prostate cancer, a disease some argue is overtreated to the detriment of patient quality of life.
One study the CAP cites found that self-referring urologists billed Medicare for 72 percent more biopsies than non-self-referring physicians; another study found that patients of urologists who own their own radiation equipment are more likely to undergo radiation therapy even when the benefit "is unclear at best," as the CAP put it.
The AMA and its peers, though, cite competing evidence suggesting that the self-referral exception has merely led to a shifting in care settings in prostate cancer treatment and other areas.
According to a Government Accountability Office study cited by the AMA coalition, after 2007 there was a "rapid increase" in self-referring groups administering intensity-modulated radiation therapy for prostate cancer, but also a decline in the service being performed in outpatient hospital settings and by non-self-referring docs.
"Overall utilization of prostate cancer-related IMRT services therefore remained relatively flat across these settings," the AMA and its peers argued in the letter to Congress.
Ending the exception could also have the unintended consequence of empowering already-consolidated health systems, the groups argue.
"Reducing the viability of the full spectrum of care being delivered in an independent outpatient setting will most likely centralize care around a few dominant hospital systems, which will undermine competition," they wrote to Congress.