Web Exclusive: Stark Law exemptions hurting residency training programs

Loopholes in the Stark Law that allow non-radiation oncologists to self-refer prostate cancer patients for treatment at facilities in which they hold a financial stake are negatively affecting residency training programs by shifting patients away from training programs and into community practices, according to a study in the April issue of the International Journal of Radiation Oncology*Biology*Physics, the official journal of the American Society for Radiation Oncology (ASTRO).

Currently, federal law prohibits a physician from referring a Medicare or Medicaid patient to an entity for certain health services if the physician or an immediate family member has a financial relationship with that entity; this law is known as the Stark Law. However, there are numerous exemptions to this law, including the in-office ancillary service exemption, which allows non-radiation oncologists to self-refer radiation therapy patients to their own practices for treatment.

The authors of this first-of-its-kind study sought to determine the impact of self-referral on radiation oncology training programs; prostate cancer treatments were used to demonstrate findings.  Eighty-one residency programs were surveyed and 73 percent responded. Of them, 50 percent said that radiation oncology facilities owned by non-radiation oncologists existed in their communities and that training programs experienced reduced patient volumes as a result 87 percent of the time.

The American Council on Graduate Medical Education, the group responsible for accrediting residency training programs in the U.S., requires that a radiation oncology training facility must treat at least 600 patients a year with external beam radiation therapy and that each resident must treat at least 450 patients with external beam radiation during the course of their four-year residency and perform at least five interstitial implants, such as brachytherapy. These guidelines are in place to ensure proper experience. The study authors determined that because prostate cancer represents a significant proportion of the caseload at academic centers, a major reduction in prostate cancer patients in academic centers could lead to the elimination of some training programs.

The in-office exemption also poses problems beyond residency training, as physicians are not required to disclose to a patient that they hold a financial interest in the facility to which they are referring them for treatment. This can lead to patients opting for more expensive technologies, sometimes unnecessarily, at the advice of their doctor, thus leading to increased healthcare costs without a commensurate benefit to patients.

 “This study shows that the Stark Law exemptions are not only hurting patients now by allowing physicians to profit off of unnecessary treatments, but they could hurt patients in the future by indirectly preventing residents from getting adequate training due to a lack of patients,” Mitchell Anscher, M.D., lead author of the study and a professor and chair of radiation oncology at Virginia Commonwealth University in Richmond, Va., said. “Congress would be wise to close this loophole in the Stark Law for the sake of all cancer patients.”