AUA maintains its support of physician-owned ancillary services

Physician ownership of ancillary services has recently been under attack in the mainstream media, and urology in particular has been the target of lobbying efforts by other specialties.

David F. Penson, M.D., MPH, clarified the AUA’s official position on physician-owned ancillary services yesterday in a Point-Counterpoint debate during the first Plenary Session of the 2011 Annual Meeting. “Protecting patient access to high quality urologic care by maintaining the in-office ancillary ownership exception remains a top legislative priority of the AUA,” said Dr. Penson, who moderated the debate.

Brent Hollenbeck, M.D., Associate Professor in the Department of Urology at the University of Michigan Health System, Ann Arbor, spoke against the practice. “It’s fitting that we are talking about this timely topic in the shadow of the Capitol. The growth of health care spending in this country is unsustainable,” said Dr. Hollenbeck, noting that health care spending reached 17.6 percent of gross domestic product in 2009 compared to 7.2 percent in 1970.

Citing an article he co-wrote that was published in The Journal of Urology® last year, Dr. Hollenbeck showed that self-employed urologists had higher rates of imaging tests ordered than hospital-employed urologists.

“Although we alluded to different possibilities that underlie these differences, one that we suggested was that the incentives afforded through ownership may be driving this trend. This drew the particular ire of the readership,” he said. “In fact, the literature is replete with examples of how self-referral is associated with higher rates of utilization.”

To combat overutilization through self-referral, the Stark Law was enacted in 1989 and has been amended numerous times. More than 20 exceptions have been written into the law because of the recognized efficiency advantages of self-referral.

“However, policymakers believe that the in-office ancillary exception — the one we’re talking about today — is the primary reason for Stark’s ineffectiveness to curtail utilization,” Dr. Hollenbeck said.

He presented data suggesting that self-referral for advanced imaging studies increases the cost for an episode of care by an average of 4 to 12 percent. He also showed data indicating that same-day delivery of in-office ancillaries is uncommon, which is in contrast to the purported efficiency cited by proponents of physician-owned ancillary services.

Peter M. Knapp, M.D., FACS, a private practice urologist and President of Urology of Indiana, countered Dr. Hollenbeck as a proponent of what Dr. Knapp termed “integrated” urological services.

“Unfortunately, physician ownership of ancillary services implemented to provide efficient care to patients has been opposed by radiologists and other non-clinicians as part of a turf battle outlined in a 1999 editorial in Radiology,” Dr. Knapp said. “The authors encouraged the national radiology organizations to engage in local turf battles to help protect radiologists against encroachment by other physicians.”

Dr. Knapp said that physician-owned ancillary services benefit patients by enhancing the physician’s ability to provide patient access to quality care, efficient service, and cost-effective medicine. Without access to in-office ancillary services, patients with urologic symptoms are sent to outside laboratories and imaging centers before going to outside hospitals for therapeutic procedures, he said.

“In Dr. Hollenbeck’s world of fragmented care with no in-office ancillary services, urologists would be unable to provide patients in-office prostate ultrasound, bladder scans, urodynamics, and laboratory services including urinalysis, semen analysis, and PSA testing,” Dr. Knapp said.

He went on to quote Paul Lange, M.D., who warned in a 2008 Journal of Urology editorial that this “fragmented” approach would eventually relegate urologists to the role of a proceduralist, depriving patients access to experts in urologic disease who could provide integrated urologic care and disease management in urology centers of excellence.

“Patients are better served in a comprehensive, integrated urology practice which includes integrated urologic services,” Dr. Knapp said. “They are no longer ancillary, but integral to the evaluation and treatment of urology patients.”

Such integrated services include laboratory, advanced imaging, radiation oncology, infusion therapy, and ambulatory surgery provided by vertically integrated participating specialists who provide in-house multidisciplinary urologic care.

Dr. Knapp cited a study of follow-up imaging utilization that compared physician-owned versus non physician-owned radiology centers. The study demonstrated that the physician-owned group was less likely to order follow-up imaging and urologists were far less likely to order it.