GAO report critical of self-referral; AUA responds

July 22, 2013

Self-referred anatomic pathology services have increased at a faster rate than non-self-referred services, according to a recent report from the Government Accountability Office that quickly drew praise from the College of American Pathologists and criticism from the AUA.

Self-referred anatomic pathology services have increased at a faster rate than non-self-referred services, according to a recent report from the Government Accountability Office that quickly drew praise from the College of American Pathologists (CAP) and criticism from the AUA.

The report states that between 2004 and 2010, the number of self-referred anatomic pathology services more than doubled, compared with an increase of approximately 38% for non-self-referred services. The GAO also observed a higher growth rate in expenditures for self-referred services compared with non-self-referred services. In 2010, it said urology, gastroenterology, and dermatology accounted for 90% of referrals for self-referred anatomic pathology services.

The study found that financial incentives for self-referring providers were likely “a major factor driving the increase in anatomic pathology referrals,” and in 2010, providers who self-referred made an estimated 918,000 more referrals for anatomic pathology services than they likely would have if they were not self referring. The Centers for Medicare & Medicaid Services estimated these additional referrals cost Medicare about $69 million in 2010.

The GAO report contained three recommendations for CMS:

  • Insert a self-referral flag on Medicare Part B claim forms and require providers to indicate whether the anatomic pathology services for which the provider bills Medicare are self-referred or not.

  • Determine and implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers.

  • Develop and implement a payment approach for anatomic pathology services that would limit the financial incentives associated with referring a higher number of specimens-or anatomic pathology services-per biopsy procedure.

The report was applauded by CAP, which says the GAO offers “irrefutable evidence that physician self-referral is a national problem,” according to a statement from CAP President-Elect Gene Herbek, MD.

While CAP applauded the GAO’s findings and call for action, it said that it disagreed with some of the GAO’s recommendations for correcting the problem.

“The only correct course of action now is to remove anatomic pathology from the In-Office Ancillary Services (IOAS) exception as quickly as possible,” said Dr. Herbek. “There is no better way to protect patients and eliminate a wasteful loophole that lets physician entrepreneurs line their pockets without any added benefit or convenience for patients.”

Meanwhile, the AUA strongly criticized the GAO study.

“The report released today by the GAO does little to advance a productive discussion around the complex issue of in-office ancillary service utilization, self-referral, and the rising costs of delivering quality care to our patients,” said AUA Health Policy Chair David F. Penson, MD, MPH, and Large Urology Group Practice Association President Deepak A. Kapoor, MD, in a statement.

“Problems with the report’s design, including the data-gathering methodology used and the analysis of physician self-referral of anatomic pathology services, are significant and were addressed in detail in past comments from both the AUA and the American Gastroenterological Association. It is noteworthy that the U.S. Department of Health & Human Services (HHS), which oversees the Medicare program, did not concur with the GAOs’ recommendations,” they added.

Dr. Penson and Dr. Kapoor characterized the GAO’s assertion that ancillary services are being utilized for financial gain as “both fundamentally wrong and offensive.”

“To label an entire profession by proposing that urologists are performing unnecessary or inappropriate biopsies to boost their bottom lines not only disparages urologists, but does a great disservice to patients. Urologists should be involved in all aspects of a prostate cancer patient’s care, including referral, diagnosis, and management of the disease. Patient access to in-office ancillary services, including laboratory services, allows for prompt treatment and ensures continuity of care while simultaneously allowing for optimal patient management by the urologist.”

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