Web Exclusive: MedPAC scrutinizes self-referral in radiation therapy, other services

By Dave Adler, assistant director of government relations

The Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare policies, met January 15, 2010, to consider addressing the in-office exception to the physician self-referral law, possibly including removal of radiation therapy from the exception. However, commissioner comments made clear significant research and discussion is needed to resolve the various policy approaches before MedPAC will be ready to make any recommendations. 

ASTRO leaders and staff had met with MedPAC staff in May 2009 and encouraged them to expand their study of self-referral in imaging to include radiation therapy. Then, in October 2009, MedPAC considered whether to do further research and possibly recommend changes to the exception in the Stark law that permits physicians to self-refer for certain services, including radiation therapy. Since October, ASTRO staff has had additional discussions with MedPAC staff members to help them further understand the process of care in radiation oncology and how self-referral is impacting practice patterns. 

At its most recent meeting, MedPAC staff presented commissioners with three policy options for addressing physician self-referral. The options include:

• Excluding outpatient therapy and radiation therapy from the in-office exception, as well as other services not usually provided at the same time as the office visit.
• Reducing payment rates for tests performed by self-referring physicians or combining multiple services into a single payment (packaging or bundling).
• A prior authorization program for physicians who self-refer for advanced imaging.

In reacting to the policy options, MedPAC Chair Glenn Hackbarth said that the commissioners almost unanimously agreed that self-referral and the in-office exception is a problem that is growing and has multiple causes. He sought input from the commissioners on whether MedPAC should expend resources to further research the problem and solutions and, if so, what is the preferred approach to addressing the problem. 

Hackbarth said his preference was to change the payment incentives involved, which he said was consistent with MedPAC's recommendations for Medicare payment to emphasize quality and value over volume of services. However, he noted that this is a technically difficult path that could take years, while the problem of self-referral persists today. He said that approaching the problem through changing the self-referral rules, such as removing services from the exception, was the second best approach, and his primary concern with that approach is that he supports efforts to move toward more organized, integrated systems of care involving care coordination across specialties, which is in essence self-referral. 

During the public comment period, ASTRO staff who attended the meeting, expressed appreciation for MedPAC's efforts on self-referral and ASTRO's support for removing radiation therapy from the exception. ASTRO staff also said ASTRO's concerns about self-referral stem largely from business arrangements that are profit-motivated. Staff noted that ASTRO would like to work with MedPAC to remove radiation therapy from the exception while avoiding a negative impact on true multispecialty, organized systems of care that focus on improving patient care, not increasing profit.

Before the public comment period, many commissioners addressed Chairman Hackbarth's questions about further research and policy preferences. All commissioners agreed that the in-office exception and self-referral should stay on MedPAC's agenda. Commissioner Mitra Behroozi noted that the exception has swallowed the rule. 

As for policy preferences, Commissioner Peter Butler said he believed radiation therapy should be removed from the exception. Commissioner Thomas Dean, M.D., also supported narrowing the exception, questioning whether both radiation therapy and physical therapy belonged. 

Several commissioners also suggested removing services from the exception where it is clear that the services are not performed on the same day of the office visit or focusing the exception on diagnostic services. Some commissioners supported a combination of approaches, with more voicing a desire to use payment policy, such as better pricing accuracy, to remove the incentive for self-referral. Some other commissioners expressed interest in prior authorization if it can be targeted at those providers where it is needed most to control over utilization, with one commissioner expressing concern about ads promoting the use of Cyberknife for prostate cancer patients. 

ASTRO staff will continue working with MedPAC as their examination continues. For more information, visit www.medpac.gov.