Web Exclusive: MedPAC continues to weigh self-referral changes

By Dave Adler, assistant director of government relations

On March 4, the Medicare Payment Advisory Commission (MedPAC) discussed potential changes to the self-referral law for radiation therapy for the third time but said it is not yet ready to make recommendations to Congress on the in-office ancillary services exception. 

ASTRO leaders and staff have been working with MedPAC for a year, calling attention to problems associated with self-referral in radiation therapy. At their most recent meeting, MedPAC staff noted that Medicare paid $104 million for radiation therapy to specialties other than radiation oncology in 2008. They said that those payments represented an 84 percent increase from 2003. However, they said that the share of spending for non-radiation oncology specialties for radiation therapy remained at 5 percent from 2003 to 2008.

Commissioners said they would like a sense of how much spending occurs as a result of self-referral before considering policy recommendations. For commissioner consideration, MedPAC staff offered the following possible self-referral policy options for radiation therapy and physical therapy:

• Excluding such services from the in-office exception.
• Excluding such services unless the practice is clinically integrated (unclear how “clinically integrated” would be defined).
• Improving payment accuracy.

Although MedPAC may be months away from considering recommendations, the recent meeting did reveal several areas of concern in addition to recognizing how best to identify abusers of self-referral and what sanctions should be used. One commissioner said he wants some idea of the cost implications, while another cautioned that certain policy changes could simply encourage physicians who currently own equipment to increase volume to make up for lower payments, as well as raising access issues in communities where physicians no longer invest in new technology. MedPAC Chairman Glenn Hackbarth acknowledged the overall conundrum, saying that the commission could become “tied up in knots” trying to think through how to put recommendations into practice.

The commission is expected to discuss self-referral in a chapter of its June report to Congress but said the chapter will not include recommendations. More work on the issue could occur in MedPAC’s next cycle of meetings beginning in the fall.

After meeting with ASTRO staff to discuss commonalities between the positions of Roswell Park Cancer Institute and ASTRO on self-referral, James Mohler, M.D., chair of the department of urologic oncology at the Roswell Park, told commissioners during the public comment session that he had testified at a House committee hearing earlier that day about problems associated with the over diagnosis and over treatment of prostate cancer (link to DeWeese story once it is posted).  Dr. Mohler said that financial incentives factors are at play leading to over diagnosis and over treatment of prostate patients, particularly in the community served by Roswell Park.  Because of what he’s seeing, he told commissioners that he supported removing radiation therapy from the in-office ancillary services exception to address this issue.

ASTRO staff is looking for opportunities to collaborate with other interested parties to close the self-referral loophole for radiation therapy.