	Background

Prostate cancer patients choose among multiple treatments that are often  considered equally appropriate but can have different risks and side  effects. Number of Prostate Cancer–Related IMRT Services Performed Increased among Self- Referring Groups— Specifically, Limited- Specialty Groups—and Decreased among Non- Self-Referring Groups

From 2006 through 2010, the number of prostate cancer–related IMRT  services performed by self-referring groups increased rapidly, while the  number performed by non-self-referring groups decreased. The number  of prostate cancer–related IMRT services performed by self-referring  groups increased from approximately 80,000 to 366,000, an annual  growth rate of 46 percent (see fig. Consistent with that growth, the  number of self-referring groups also increased rapidly over the period. In contrast, self-referring providers who belonged to a multispecialty group referred approximately  36 percent of their patients diagnosed with prostate cancer in 2007 or  2009 for IMRT, only moderately higher than the 33 percent of non-self- referring providers’ patients diagnosed with prostate cancer in 2007 or  2009 who were referred for IMRT. While providers that did not begin to self-refer— that is, self-referrers and non-self-referrers—referred different  percentages of their patients who were diagnosed with prostate cancer in  2007 for IMRT, the percentages of their patients they referred for IMRT  remained relatively consistent over the same period when switchers  dramatically increased the percentage of their patients they referred for  IMRT. However, our review indicates that Medicare  providers that self-referred IMRT services—particularly those practicing in  limited-specialty groups—were substantially more likely to refer their  prostate cancer patients for IMRT and less likely to refer them for other,  less costly treatments, especially brachytherapy or a radical  prostatectomy, compared to providers who did not self-refer. Without a way to identify self- referred services, such as a self-referral flag on Medicare Part B claims,  CMS does not have the ongoing ability to monitor self-referral and its  effects on beneficiary treatment selection and costs to both Medicare and  beneficiaries. In addition, Medicare providers who self-refer IMRT services are  generally not required to disclose their financial interest in IMRT. Thus,  beneficiaries may not be aware that their provider has an incentive to  recommend IMRT over alternative treatments which may be equally  effective, have different risks and side effects, and are less expensive for  Medicare and beneficiaries. Currently, the Department of  Health and Human Services (HHS), the agency that administers CMS,  lacks the authority to establish a disclosure protocol for providers who  self-refer IMRT services. Matter for Congressional Consideration

To increase beneficiaries’ awareness of providers’ financial interest in a  particular treatment, Congress should consider directing the Secretary of  Health and Human Services to require providers who self-refer IMRT  services to disclose to their patients that they have a financial interest in  the service. AUA representatives said we did not have sufficient evidence to link  financial incentives to the increase in IMRT use among self-referring  providers and disagreed with our conclusion that financial incentives for  self-referring providers belonging to limited specialty groups were likely a  major factor driving the increase in the percentage of prostate cancer  patients referred for IMRT. Appendix I: Scope and Methods

This section describes the scope and methodology used to analyze our  two objectives: (1) comparing trends in the number of and expenditures  for Medicare prostate cancer–related intensity-modulated radiation  therapy (IMRT) services provided by self-referring and non-self-referring  groups from 2006 through 2010 and (2) examining how the percentage of  Medicare prostate cancer patients referred for IMRT may differ on the  basis of whether providers self-refer.
Why GAO Did This Study

Questions have been raised about self-referral's role in Medicare Part B expenditures' rapid growth. Self-referral occurs when a provider refers patients to entities in which the provider or the provider's family members have a financial interest. Services that can be self-referred under certain circumstances include IMRT, a common and costly treatment for prostate cancer. GAO was asked to examine Medicare self-referral trends among radiation oncology services. This report examines (1) trends in the number of and expenditures for prostate cancer-related IMRT services provided by self-referring and non-self-referring provider groups from 2006 through 2010 and (2) how the percentage of prostate cancer patients referred for IMRT may differ on the basis of whether providers self-refer. GAO analyzed Medicare Part B claims and developed a claims-based methodology to identify self-referring groups and providers. GAO also interviewed officials from the Centers for Medicare & Medicaid Services (CMS), which administers Medicare, and other stakeholders.

What GAO Found

The number of Medicare prostate cancer-related intensity-modulated radiation therapy (IMRT) services performed by self-referring groups increased rapidly, while declining for non-self-referring groups from 2006 to 2010. Over this period, the number of prostate cancer-related IMRT services performed by self-referring groups increased from about 80,000 to 366,000. Consistent with that growth, expenditures associated with these services and the number of self-referring groups also increased. The growth in services performed by self-referring groups was due entirely to limited-specialty groups--groups comprised of urologists and a small number of other specialties--rather than multispecialty groups.
Providers substantially increased the percentage of their prostate cancer patients they referred for IMRT after they began to self-refer. Providers that began self-referring in 2008 or 2009--referred to as switchers--referred 54 percent of their patients who were diagnosed with prostate cancer in 2009 for IMRT, compared to 37 percent of their patients diagnosed in 2007. In contrast, providers who did not begin to self-refer--that is, non-self-referrers and providers who self-referred the entire period--experienced much smaller changes over the same period. Among all providers who referred a Medicare beneficiary diagnosed with prostate cancer in 2009, those that self-referred were 53 percent more likely to refer their patients for IMRT and less likely to refer them for other treatments, especially a radical prostatectomy or brachytherapy. Compared to IMRT, those treatments are less costly and often considered equally appropriate but have different risks and side effects. Factors such as age, geographic location, and patient health did not explain the large differences between self-referring and non-self-referring providers. These analyses suggest that financial incentives for self-referring providers--specifically those in limited specialty groups--were likely a major factor driving the increase in the percentage of prostate cancer patients referred for IMRT. Medicare providers are generally not required to disclose that they self-refer IMRT services, and the Department of Health and Human Services (HHS) lacks the authority to establish such a requirement. Thus, beneficiaries may not be aware that their provider has a financial interest in recommending IMRT over alternative treatments that may be equally effective, have different risks and side effects, and are less expensive for Medicare and beneficiaries.

What GAO Recommends

Congress should consider directing the Secretary of Health and Human Services, whose agency oversees CMS, to require providers to disclose their financial interests in IMRT to their patients. GAO also recommends that CMS identify and monitor self-referral of IMRT services. HHS disagreed with GAO's recommendation. Given the magnitude of GAO's findings, GAO maintains CMS should identify and monitor self-referral of IMRT services.