can we talk about urorad?

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I agree with the problem as you identify it. I guess where I differ is the notion that a federally concocted "one size fits all" approach will meaningfully address these issues without a massive backlash of unintended consequences. Even solutions on a state level would be preferable, as different states will necessarily be facing different situations in this arena.

More specific to the discipline of radiation oncology (and back to the topic of the thread), some of the commendable first steps being taken are 1) consideration of making facility ACR accreditation mandatory, and 2) the initiation of an investigation into self-referral practices in free-standing radiation facilities by the GAO. The first of these will only scare those practices that are grossly out of compliance, and many of those are likely to the the "problem children" you allude to. The second is aimed squarely at urorads.

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More specific to the discipline of radiation oncology (and back to the topic of the thread), some of the commendable first steps being taken are 1) consideration of making facility ACR accreditation mandatory, and 2) the initiation of an investigation into self-referral practices in free-standing radiation facilities by the GAO. The first of these will only scare those practices that are grossly out of compliance, and many of those are likely to the the "problem children" you allude to. The second is aimed squarely at urorads.

I am personally seeing the consequences of the Uro rad self-referral problem. We ahve two groups of urologists that have sent us patients for years. Presumably we have been giving (and I believe we continue to give) high quality care. One group here has joined w a uro-rad type practice and all of a sudden their referrals have decreased substantially. We still get their HMO, & Medicaid patients as well as those who dont understand why they should drive 17 miles to the "prostate center". Of course, they offer "GPS for the prostate" while we use "older gold seed fiducials".
 
One size fits all will not really work, but if we continue to get paid for quantity rather than quality, not much will save us. The opposite, i.e. pure capitation approach, would cause us to under-tx. There needs to be incentives for doing the right thing, all the time. There are enough diseases that are 'cookbook' enough that some quality incentives could be instituted, and I think that's part of the solution, rather than incentivizing how many fractions or the most expensive treatments.

By the way, Shmuel is someone completely different, lest you all be confused.

-S
 
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I am personally seeing the consequences of the Uro rad self-referral problem. We ahve two groups of urologists that have sent us patients for years. Presumably we have been giving (and I believe we continue to give) high quality care. One group here has joined w a uro-rad type practice and all of a sudden their referrals have decreased substantially. We still get their HMO, & Medicaid patients as well as those who dont understand why they should drive 17 miles to the "prostate center". Of course, they offer "GPS for the prostate" while we use "older gold seed fiducials".

Your last line caught my interest. The urorads center in town had EXTRAORDINARY claims on their website: Saying they were the only center in town with IGRT, IMRT, and electrons (!), they had far superior equipment, etc. They have a Varian IX. I had to remind the radonc there that:

a. one of our partners within 1000 feet of their clinic has not one but two IXs
b. making false claims about superiority does not please the state medical board

I couldn't believe what I saw on the website. Be sure to keep an eye out for this stuff.
 
Your last line caught my interest. The urorads center in town had EXTRAORDINARY claims on their website: Saying they were the only center in town with IGRT, IMRT, and electrons (!), they had far superior equipment, etc. They have a Varian IX. I had to remind the radonc there that:

a. one of our partners within 1000 feet of their clinic has not one but two IXs
b. making false claims about superiority does not please the state medical board

I couldn't believe what I saw on the website. Be sure to keep an eye out for this stuff.

What do they do with their electrons? Boost the groin?
 
Front and center in the WSJ....

A Device to Kill Cancer, Lift Revenue .

The Wall Street Journal, together with the nonprofit Center for Public Integrity, obtained a 5% sample of all Medicare billing, but was unable to form an accurate picture of self-referring urology groups' treatment patterns from the sample. The Journal subsequently obtained 100% of these groups' billings from the Department of Health and Human Services for an additional fee. The Journal agreed not to publish billings of individual doctors. Instead, it is restricted to analyzing groups of 10 or more physicians.

A Journal analysis of Medicare claims suggests that IMRT usage is significantly higher in the five states where most of the urology groups that own radiation equipment are located. These states—New York, Florida, Pennsylvania, New Jersey and Texas—are home to 22 of the 37 self-referral groups identified by the Journal. The average IMRT usage for recently diagnosed prostate-cancer patients was 42% in those states in 2008. By contrast, the national average was about a third.
They even list all 37 of the urorad groups in the pop-up graphic on the left hand side of the article.

Between this and the recent NEJM study on hormone use and reimbursement, urologists are getting plenty of good PR these days....
 
Front and center in the WSJ....

A Device to Kill Cancer, Lift Revenue .




They even list all 37 of the urorad groups in the pop-up graphic on the left hand side of the article.

Between this and the recent NEJM study on hormone use and reimbursement, urologists are getting plenty of good PR these days....


Something tells me ASTRO just found its new handout for Advocacy Day.
 
Man, that is a damning article.
I wish pestilence and famine on Urorad and the like.
-S
 
it kills me that a Rad Onc was the one who came up with the whole urorads idea....
 
Nice piece of research from WSJ.
Notice that how often IMRT as a modality mentioned in the article. IMHO, public scrutiny on IMRT utilization is long overdue.
 
Apparently Chesapeake Urology is facing scrutiny about attempts to overturn Maryland anti-self-referral laws. So far, so good. This could be a good example to follow in other states or as precedent for federal/CMS interpretation.
 
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The biggest abusers of self referral are HOSPITALS that control the radiation oncologist via exclusive contracts that terminate the Doctors access to expensive equipment with little notice and with no regard towards quality. Hospitals which pay no taxes routinely demand that the radiation oncologist only treat at one location their hospital; the radiation oncologist is prohibited from practicing at multiple hospitals or a freestanding center. It takes 2-3 years to build a radiation center and $6 million in capital. If a hospital administrator can destroy your practice with 180 day notice that is a huge financial incentive to make sure that you have a place to treat patients. Radiation Docs have reported hospital administrators questioning their treatment decisions with regards to number of treatments as more treatments generate more money for the hospital. Hospitals are routinely buying up the private practices that refer patients for radiation therapy and diagnostic Xrays yet the patients are not aware that they are being referred based on financial ties. Since 80% of all radiation centers are hospital based the real issue is not 75 urology owned radiation centers but rather the community based nonprofit hospital centers that use exclusive contracts to control the radiation oncologist. Demand that the nonprofit hospitals have open staffs in rad onc that will reduce the problem
 
The article is obviously incorrect in suggesting that RadOncs don't have incentives to prescribe more expensive treatments. Those of us who take a cut of technical fee is the most straightforward example.

Apparently Chesapeake Urology is facing scrutiny about attempts to overturn Maryland anti-self-referral laws. So far, so good. This could be a good example to follow in other states or as precedent for federal/CMS interpretation.
 
Your post is hard to read, but yes, I find it insulting when an administrator tracks the average number of fractions that you prescribe.

The biggest abusers of self referral are HOSPITALS that control the radiation oncologist via exclusive contracts that terminate the Doctors access to expensive equipment with little notice and with no regard towards quality. Hospitals which pay no taxes routinely demand that the radiation oncologist only treat at one location their hospital; the radiation oncologist is prohibited from practicing at multiple hospitals or a freestanding center. It takes 2-3 years to build a radiation center and $6 million in capital. If a hospital administrator can destroy your practice with 180 day notice that is a huge financial incentive to make sure that you have a place to treat patients. Radiation Docs have reported hospital administrators questioning their treatment decisions with regards to number of treatments as more treatments generate more money for the hospital. Hospitals are routinely buying up the private practices that refer patients for radiation therapy and diagnostic Xrays yet the patients are not aware that they are being referred based on financial ties. Since 80% of all radiation centers are hospital based the real issue is not 75 urology owned radiation centers but rather the community based nonprofit hospital centers that use exclusive contracts to control the radiation oncologist. Demand that the nonprofit hospitals have open staffs in rad onc that will reduce the problem
 
The article is obviously incorrect in suggesting that RadOncs don't have incentives to prescribe more expensive treatments. Those of us who take a cut of technical fee is the most straightforward example.

It would make more sense if the law said neither referring nor prescribing physicians were allowed to own the machines. But that's not how lobbying works, as far as I understand it... :D
 
The article is obviously incorrect in suggesting that RadOncs don't have incentives to prescribe more expensive treatments. Those of us who take a cut of technical fee is the most straightforward example.

It would make more sense if the law said neither referring nor prescribing physicians were allowed to own the machines. But that's not how lobbying works, as far as I understand it... :D

The thing to remember is that we are still at the end of the referral food chain, by and large, unlike the urologists and orthopods who can actually self-refer to their own XRT and radiology facilities. We don't self-refer. The referrals come to us. Very similar situation to radiologists that own their own equipment.
 
The thing to remember is that we are still at the end of the referral food chain, by and large, unlike the urologists and orthopods who can actually self-refer to their own XRT and radiology facilities. We don't self-refer. The referrals come to us. Very similar situation to radiologists that own their own equipment.

In the end, this is just an old fashioned turf battle.

As far as framing it as an ethical issue, diagnostic radiology looks much cleaner than rad onc.

Certainly being higher up the chain, like urologists, means being in a better position to exploit referrals / prescriptions.
 
Chesapeake Urology is a distant competitor as they are 30 miles from our nearest center.

They are in flagrant violation of the law as stated by the state of Maryland. I don't understand how they are able to avoid litigation and/or be shut down. The article and the clear lack of enforcement of the rules is disturbing. It's been going on for a few years, cutting into the major Baltimore centers (JHH, UMD, Mercy, Franklin Square) and probably eating away at some of our northern sites.

I'm curious as to how it shakes out, because they are flaunting the rules in the light of day, and we are just getting shouted down.

S
 
Was wondering what you all thought about the recent Health Affairs article which has re-ignited controversy regarding the growth of IMRT usage for prostate, especially by large urology centers. It seems ASTRO is trying to invoke the Stark Law's ban on self referral to try to shut down these centers.

https://www.astro.org/News-and-Medi...dy-on-growth-of-IMRT-for-prostate-cancer.aspx

Will there be a backlash against IMRT by the public/payers?
If reimbursements have truly fallen by 30% for IMRT as claimed by ASTRO, what incentive is there for these urology practices to push IMRT?
Will ASTRO be successful in curbing urology encroaching on IMRT?
 
At some point in the future, Medicare reimbursement will switch from a pay-for-service to a case rate. Thus, rather than perversely incentivizing prolonged fractionation they will simply give a flat fee which you can use to do whatever you like (RP, LDR, HDR, IMRT). This should "encourage" hypofractionation and brachy.

Nobody knows when this transition will happen, but it is inevitable.
 
It is a fact of life that some unethical docs will steer patients to higher reimbursing modalities. Urorads is certainly one such example, but there are many, many others (can anyone show me that compelling data for protons again? anyone?)

Every specialty does it, we only get indignant about it when one specialties transgressions cut into another specialties bottom line. This infighting (ASTRO vs. AUA, etc.) will only serve to allow more and more government regulation of physician prescribing practices, and continue to reduce physician autonomy and the ability of physicians to enter private practice, while large hospital corporations continue to grow. Ultimately physician ownership of technical equipment and collection of technical fees may become a thing of the past.

A urologist (whose salary + RVU bonus is paid by the hospital) who refers a patient to the hospital owned IMRT machine can have just as much a conflict of interest as one who owns his own machine, but we only hear outcry against the latter.
 
When we study how many rad oncs that own equipment prescribe active surveillance rather than IMRT as compared to those at an academic center is when I'll believe that we are pushing these investigations for the right reason. Until then, we can continue our red faced indignation but hopefully those of us with any sense of a moral compass should maybe take a pass instead of taking a shot at urorads.

My practice takes a global fee, but I haven't been prouder since today when my partner offered no RT for low risk breast cancer and was screamed at by the patient while she stood her ground.

S
 
When we study how many rad oncs that own equipment prescribe active surveillance rather than IMRT as compared to those at an academic center is when I'll believe that we are pushing these investigations for the right reason. Until then, we can continue our red faced indignation but hopefully those of us with any sense of a moral compass should maybe take a pass instead of taking a shot at urorads.

My practice takes a global fee, but I haven't been prouder since today when my partner offered no RT for low risk breast cancer and was screamed at by the patient while she stood her ground.

S

Fair enough, But there is no self referral there. We aren't working up the elevated PSA and diagnosing prostate CA.

I, like you, am also in the global fee crowd and it almost feels like I'm the one who pushes AS/WW the most after being the referral.
 
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dont you guys think advocating for more government regulation is going to end up hurting rad oncs also? right now government needs any excuse to cut down on reimbursements to physicians, havent we learned that increased governement regulation of medicine isnt always a good thing...with the increasing publicity by NYT the set is being staged for increased government regulation of radiation treatment and if you guys think theyre only going to "de-incentivize" the use of radiation therapy by self-referring urologists only, you'll be in for a shock..and considering the public doesnt know much about radiation therapy and it is relatively easy for politicians to argue that rad oncs are getting over-paid (they'll spin it as rad oncs "exploiting" cancer patients for increased revenue), this makes rad oncs safe and very easy political targets...just be careful for advocating for too much government regulation in your own domain especially when you're already vulnerable...fight the urorads without increased government involvement

this is sad to say but it is the truth: cancer is a hot & controversial political topic---if rad oncs can better educate the public on their role in cancer care, rad oncs will always have the upper hand..whenever there is a cut in reimbursements to rad treatment the PR team of ASTRO should immediately contact NYT to publish articles about how the government cut treatment for cancer..not saying it'll always work but this does put pressure on politicians not to support cuts..unfortunately most doctors don't have the time, interest or knowledge of how to play the game of politics but unfortuantely you have to play these tactics for the sake of your field..
 
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this is sad to say but it is the truth: cancer is a hot & controversial political topic---if rad oncs can better educate the public on their role in cancer care, rad oncs will always have the upper hand..whenever there is a cut in reimbursements to rad treatment the PR team of ASTRO should immediately contact NYT to publish articles about how the government cut treatment for cancer

ASTRO would rather fight free-standing multispecialty and urorads groups by attacking the self-referral exemption. What you've posted is true.

I agree that ASTRO should focus its efforts on public awareness and avoiding cuts at all rather than trying to legislate against particular groups. This fight over self-referral in radiation oncology (as well as pathology and advanced imaging services) has apparently created strange bedfellows with groups such as the AUA and AMA who are positioned to oppose ASTRO on this.

Medpage Today said:
More than 30 national medical groups -- including the American Medical Association, the American College of Surgeons, and the American Urological Association -- wrote a letter to all members of Congress Monday opposing the legislation. They argued that the Stark Law exemptions encourage care coordination and that removing them would create barriers to more integrated delivery.

"If enacted, this bill would limit access to life-saving services for many patients and stifle new innovative reforms already underway to improve care delivery and quality improvement," the letter stated. "It would raise the costs to Medicare beneficiaries and the Medicare program by driving patients to more costly facilities, thereby requiring additional expenditures."
 
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this is sad to say but it is the truth: cancer is a hot & controversial political topic---if rad oncs can better educate the public on their role in cancer care, rad oncs will always have the upper hand..whenever there is a cut in reimbursements to rad treatment the PR team of ASTRO should immediately contact NYT to publish articles about how the government cut treatment for cancer..not saying it'll always work but this does put pressure on politicians not to support cuts..

We can do even better than that. Now that we treat left-sided breast cancer with IMRT, we should be publishing articles like "Government again aims to cut breast cancer benefits."
 
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Okay.. question. How does it benefit the patient if any physician is allowed to own any capital equipment that they generate money off of its use? I.e. why should we even be owning the equipment? I see the business reason, but I'm not sure if our clinical or patient-care arguments are any stronger than the urologists.

- They say it's hard for independent physicians to compete against hospitals without the exception. I think that a radonc owner of a freestanding center would say the same thing.

- They say it allows them to provide "global care". I can see a joint medonc/rad onc group owning the facility saying the same thing.

- They say that if the hospital is allowed to do it, why shouldn't we be allowed to? (Own and make money off of equipment). That's what a freestanding owner would say, as well.

- If my practice bought the equipment and disintegrated the partnership with the 4 independent hospitals that own our 2 centers, I'm not sure what would change. The hospitals are also doing the diagnosis, work up, and then referring to us (which is just an extension of them).

So ... The reason why we don't like it, on paper, is because the utilization rate changes - i.e. urologists stop doing RRP and brachytherapy, and refer for IMRT. But, say the same center becomes a radiation owned facility and one could show that fractionation is prolonged at freestanding centers (as studies show). Then, the same arguments can be used against ownership by radiation oncology. Because the outcome is the overutilization, not the referral itself. If people self referred and had the same rates of IMRT as compared to non-urologist owned facilities, there wouldn't a good argument to stop this.

To say its just because when we own our centers it isn't self-referral is ignoring the elephant in the room... I'm not saying we shouldn't aggressively go after Urorad and the like. They are ruining medicine. But, it's disingenuous to say that self-referral is a bigger issue than the overutilization.

S
 
Okay.. question. How does it benefit the patient if any physician is allowed to own any capital equipment that they generate money off of its use? I.e. why should we even be owning the equipment? I see the business reason, but I'm not sure if our clinical or patient-care arguments are any stronger than the urologists.




So ... The reason why we don't like it, on paper, is because the utilization rate changes - i.e. urologists stop doing RRP and brachytherapy, and refer for IMRT. But, say the same center becomes a radiation owned facility and one could show that fractionation is prolonged at freestanding centers (as studies show). Then, the same arguments can be used against ownership by radiation oncology. Because the outcome is the overutilization, not the referral itself. If people self referred and had the same rates of IMRT as compared to non-urologist owned facilities, there wouldn't a good argument to stop this.

To say its just because when we own our centers it isn't self-referral is ignoring the elephant in the room... I'm not saying we shouldn't aggressively go after Urorad and the like. They are ruining medicine. But, it's disingenuous to say that self-referral is a bigger issue than the overutilization.

S

To address the prolonged fractionation issue, you move the payment model to a flat fee DRG-type system for a given diagnosis.

Problem solved. I really wish Maryland would study the before and after of removing those exemptions because as you well know, only radiologists can own scanners and rad oncs own machines there, besides hospitals obviously.
 
re: Maryland

My understanding is that what you say is true with respect to the written law, but the law is not being enforced. Perhaps this is no longer true though.
 
They operate with impunity. We've testified against them in Maryland State court.

The People's Republic of Maryland enforces laws as they see fit, not as they are written. Ask JHH or UMD how much prostate they see. They do less seeds than our group, at least as of a few years ago.

They have gone rogue, laws mean nothing to them. Either we forget about trying to close the loophole or Medicare needs to recognize they are violating state law and stop reimbursing them.
 
To address the prolonged fractionation issue, you move the payment model to a flat fee DRG-type system for a given diagnosis.

Problem solved.

If only it were so easy. All global payments will do is switch the trend from hyPER to hyPOfractionation. And then what will radoncs do with all their spare linac time? Something tells me that radiation therapy utilization rates for various borderline indications would increase.

Once again, I'm not bashing radoncs. Its every specialty. People will act to maximize revenue, and unfortunately some physicians in any field will push that too far.
 
If only it were so easy. All global payments will do is switch the trend from hyPER to hyPOfractionation. And then what will radoncs do with all their spare linac time? Something tells me that radiation therapy utilization rates for various borderline indications would increase.

Once again, I'm not bashing radoncs. Its every specialty. People will act to maximize revenue, and unfortunately some physicians in any field will push that too far.

Isn't a global payment system how things happen in Canada? Are you suggesting that our canadian counterparts are more likely to treat for borderline indications?

Again, nothing will be a perfect system, but IMO it makes absolutely no sense for anyone outside of rad oncs, hospitals or mutlispeciality groups/ACOs to own eqiupment. The urorads model is rife with abuse. Excessive fractionation in the community is something that can be fixed with payment reform.

In fact, some insurance companies do this with the authorization process. You have to submit how many Fx you are treating, what technique, etc. The most egregious groups that treat everyone with 60 Fractions given in a BID fashion would not get authorized if they submitted more than 44 Fx for prostate CA, or more than 35-37 Fx for Breast CA etc.
 
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Okay.. question. How does it benefit the patient if any physician is allowed to own any capital equipment that they generate money off of its use? I.e. why should we even be owning the equipment? I see the business reason, but I'm not sure if our clinical or patient-care arguments are any stronger than the urologists.

We agree on a lot of things, but I can't really endorse this view. In California, the corporate practice of medicine is illegal. Specifically "laypersons or lay entities may not own any part of a medical practice. Physicians must either own the practice, or must be employed or contracted by a physician-owned medical corporation or practice."

Medicine is for profit. You can either give most of the profit to hospital administrators or you can take it for yourself. If it helps you to sleep better at night doing the former, then so be it.

To say its just because when we own our centers it isn't self-referral is ignoring the elephant in the room... I'm not saying we shouldn't aggressively go after Urorad and the like. They are ruining medicine. But, it's disingenuous to say that self-referral is a bigger issue than the overutilization.

Urorads is a financial model where all patients with non-metastatic prostate cancer are funneled into the most highly reimbursed form of medical care. Patients are not given alternative options of RP, LDR, HDR, or AS. This is BAD MEDICINE.

Overutilization is common to all specialties and will continue to be a problem while the current fee-for-service model remains in place.
 
What I mean is the argument stops making sense by separating one group from the other. Because down the line, the exact same arguments we use to stop Urorad will be used against us. So, my point is that we end up restricting their ownership, but down the line, some entity will try to close the loophole for us. For a freestanding center, the hospital is the enemy. Right now its ASTRO vs CockPAC. Maybe down the road it's ASTRO vs AHA.

Say Urorads was practicing "good medicine". Then does it make it okay that they own radiation facilities? And who's the say what is "good medicine"? Is there an arbitrary number of patients that aren't treated with IMRT that makes it that your facility is practicing "good medicine" vs "bad medicine"? Who decides this number? Is it Jean what's her name from up the road in DC that's publishing this stuff (and it is good stuff)? Or will it be the Feds? And what about medonc-radonc partnerships? Some of us don't have the capital to go all in, and having a chemo-sabe as a financial partner might make it so a community can have a comprehensive cancer center.

I don't think the $$ should necessary go to the community hospital or the county or the anyone in particular. It's just by singling one group out right now, it might hurt us in the long run.

S
 
When you practice in the real world let me know, for now, you speak in hypotheticals. Most rad oncs including myself treat based on evidence based guidelines, I dont add fractions to keep people on beam. Your wording speaks to your ignorance, not many of us in the community hyperfractionate with the exception of limited stage small cell, some head and neck, etc. Will global payments push us to cut fractions, possible but only if data supports it. I see research moving that way and if its justified to shorten course with comparable outcomes and toxicity great for the patient and me, if not you wont see most of us pursuing it.

I agree. Most doctors (radoncs and urologists included) base their decisions on what is best for the patient.

But you can't deny that abuses occur in any specialty, especially when there isn't good data. For example, there's no great data comparing new IMRT treatments for prostate to nerve sparing prostatectomy in outcomes and morbidities. Likewise, I am unaware of any prospective RCTs demonstrating the clinical superiority of proton therapy. Would you argue that no radoncs inappropriately use more expensive modalities when there is no data showing supriority over less expensive modalities?
 
I agree abuses occur in all specialties; however, it has been my experience that when urologists make the decision to buy into a radiation center the abuse is part of the plan not a byproduct of the situation. Its also my experience that urologists in the community more often use expensive/higher reimbursing modalities even when they are contraindicated- robotic prostatectomy in high risk prostate, cryoablation for de novo prostate cancer. I dont know of many radoncs do anything as unethical as that yet it is commonplace in the community.

The prostatectomy vs. RT argument is unlikely to ever face a randomized trial; however, a study was published in NEJM this year which basically confirmed what we knew. RT= prostatectomy with differences in toxicities. What shocks me is when urologists get angry when you discuss the incontinence and impotence rates from surgery in this study and the JCO study on robotic prostatectomy, they dont want patients knowing what published data is about their technique. As for protons, I dont believe in protons for many things beyond pediatric tumors, re-treatment, base of skull and this protons for prostate is ridiculous.

Yup. It's been pervasive in the urology community. Before urorads and cryo, there was inappropriate lupron usage back when it paid really well

http://www.nejm.org/doi/full/10.1056/NEJMsa0910784
 
Why is it that urologists are like this? Is this pervasive in other specialties? Is this just because they are our frenemies? Very few NEJM articles flat out call a certain specialist as fraudulent. The people that I knew that got into urology were not squirrelly. I wish we could get urologists or urology residents to contribute and give their views/defend themselves.
 
I agree abuses occur in all specialties; however, it has been my experience that when urologists make the decision to buy into a radiation center the abuse is part of the plan not a byproduct of the situation.

This has been a very interesting discussion. I can add some personal experience as I've done (and still occasionally do) locums work for two big urorads centers. I worked a lot for these guys, and I can honestly say I never saw (or see) a case of a patient who qualifies for surveillance being treated with RT. I just haven't. I just covered for a guy the other day, and based on this discussion, read the history of every patient under treatment. Nothing of even borderline suspicion. Granted, this is an n=2, but this has been my experience. As to what motivates these guys, I don't think there's any surprise that it's money. These urologists are very honest: somebody has to own the equipment. It's either them or a hospital administrator. So pick your poison. I do know that urorads centers reimburse radiation oncologists extremely well...much better than the salaried positions these hospitals offers. I also know that in my own community, the local hospital is playing a far bigger role in crunching out private practice rad oncs than any urorads center. As someone mentioned previously, they're trying to buy out all of the practices--medical oncology, surgery, etc--that can refer to radiation oncology. So at least in my community, I'd take the urorads center over the hospital any day.
 
I enjoy the counter-intuitive, Reaganite.
I just stopped believing its as black and white as people say.
A friend of mine works for a multi-specialty owned clinic and though they are very concerned about numbers and ask about picking up business, the sentiment is to beat the other guys in town, not to treat 84 year old men with psa 5, Gleason score 6 disease.
The hospital is the issue, FFS is an issue; IMRT reimbursement is an issue, lack of oversight is an issue, but stark law loophole is just a distraction from these issues.
 
What I mean is the argument stops making sense by separating one group from the other. Because down the line, the exact same arguments we use to stop Urorad will be used against us.

How?

Perhaps from an overutilization standpoint, but likely not from a self-referral standpoint. Again, payment reform will address the former, possibly, while self-referral legislation against third party single-practice ownership will address the latter.

Until rad oncs start getting PCP referrals for elevated PSAs and start working them up and doing their own biopsies, the argument will never cross that line. Fundamentally, we require GU referrals to exist. When the patient comes to see us, they've already seen the GU typically and have received other options like RP, AS, cryo, HIFU, etc. When the GU starts taking an ownership component in OUR practice, and starts sending everyone for XRT, that's BAD medicine as Gfunk eluded to and such self-referral will be called out for the abuse that it is.

I don't think the $$ should necessary go to the community hospital or the county or the anyone in particular. It's just by singling one group out right now, it might hurt us in the long run.

S

That one group is being egregious in self-referral. If you start to see ENTs or neurosurgeons buy rad onc practices and start sending every CA case for radiation, you'd see a similar argument against them as well. I've heard of some pretty ridiculous CK setups owned by surgical specialists where some pretty wild cases were being referred for CK/XRT.
 
One thing that I don't see talked about is the potential for the double dip. It may be because it is not as big as issue as it it could be. I attribute this, in part, to the lack of evidence based practices by many urologists. Many still do not grasp the concept of the benefits for adjuvant post-prostatectomy radiation. But the scenerio would go as follows: Urologist would take an inappropriate patient for prostatectomy (say 8/12 cores gleason 8 with PSA of 15) knowing that the patient would need post op RT . Then 4 months later giving the patient post-prostatectomy IMRT (on the machine he has ownership in) for positive margin or T3 disease. I wonder how often the double dip occurs? Seems like the biggest abuse potential.
 
One thing that I don't see talked about is the potential for the double dip. It may be because it is not as big as issue as it it could be. I attribute this, in part, to the lack of evidence based practices by many urologists. Many still do not grasp the concept of the benefits for adjuvant post-prostatectomy radiation. But the scenerio would go as follows: Urologist would take an inappropriate patient for prostatectomy (say 8/12 cores gleason 8 with PSA of 15) knowing that the patient would need post op RT . Then 4 months later giving the patient post-prostatectomy IMRT (on the machine he has ownership in) for positive margin or T3 disease. I wonder how often the double dip occurs? Seems like the biggest abuse potential.

with the worst morbidity.

It's amazing how many GUs I continue to run into who are oblivious to (or just don't care to learn) the guidelines/data for post-RP XRT. This despite the fact that AUA/ASTRO has issued consensus guidelines on this very topic. The ones that own the LINACs might be doing the double dip, while others are simply watching post-op T3 disease with rising PSAs until it gets to a ridiculous level.
 
Good points!

I'm not sold on adjuvant RT. With ultra-sensitive PSA testing and good follow-up, as long as they get sent to me before PSA reaches 1.0, I don't mind just watching patients with +margins or pT3a. T3b are going to fail distantly, but heck, lump them in there, too. As the data shows, 30-70% won't fail and won't need RT. I think a balance of watching PSA and early salvage is a cost-effective, low morbidity approach, and I think the consensus guidelines reflected that approach, as an alternative. The control arms treated with salvage RT way too late when the PSA would be 6 or something crazy and there is no way to salvage those folks.

Been giving most of them 6 months of ADT, too.
 
I'm not sold on adjuvant RT. With ultra-sensitive PSA testing and good follow-up, as long as they get sent to me before PSA reaches 1.0, I don't mind just watching patients with +margins or pT3a. T3b are going to fail distantly, but heck, lump them in there, too. As the data shows, 30-70% won't fail and won't need RT. I think a balance of watching PSA and early salvage is a cost-effective, low morbidity approach, and I think the consensus guidelines reflected that approach, as an alternative. The control arms treated with salvage RT way too late when the PSA would be 6 or something crazy and there is no way to salvage those folks.

Been giving most of them 6 months of ADT, too.

I use the data from the german study looking at a wait-and-see approach vs adjuvant RT in terms of a bPFS benefit. I don't believe the updates have shown a metastasis-free survival benefit as of yet, but if I can prevent people from going on to Lupron (which the SWOG study also demonstrated) and give them a bPFS benefit, I like to offer it to my T3 patients especially when I can counsel them on the 0.3% risk of G3-4 toxicity.

I think the risk factor of a +margin alone is a more nuanced conversation.

I know the RTOG is currently studying it, but I am also one of those people that likes to give 4-6 mos of ADT during XRT for bad disease (T3, G8, etc.... I'll go 1-2 years for +nodes).
 
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