William J. Scanlon, PhD, Senior Consultant & Sally Coberly, PhD
Research over the past 20 years, including four recent reports issued over the past two years by the U.S. Government Accountability Office (GAO), has underscored that physicians with a financial interest in prescribed services ("self-referrers") tend to order more of those services than their non-self-referring counterparts. To address concerns of physicians' financial conflicts of interest, "The Ethics in Patient Referral Act" was enacted in 1989. Commonly known as the "Stark" law (after its sponsoring congressman), it barred Medicare payment for services where the ordering physician has a financial interest, although it did allow for an exception for the sake of patient convenience that would pay for services provided in the physician's own office. Since then, the provision of office-based services has increased, adding significantly to Part B spending as new technologies and procedures have become more feasible to provide in the office. How best to address this situation—elimination or curtailment of the in-office exception, payment reforms, or utilization management—has been the focus of much discussion. At this Forum session, speakers reviewed the findings of the GAO reports and the agency's recommendations; discussed the Medicare Payment Advisory Commission's analysis regarding self-referral and its recommendations to address the issue in the context of broader payment reform; and described how health plans use prior authorization to ensure the appropriate use of services, especially among high-utilization physicians (self-referrers and others).
James Cosgrove, PhD (bio)
Director, Health Care
U.S. Government Accountability Office
Mark Miller, PhD (bio)
Medicare Payment Advisory Commission
Susan Nedza, MD, MBA, FACEP (bio)
Chief Medical Officer
AIM Specialty Health
See the four studies conducted by the U.S. Government Accountability Office (GAO) on physician self-referral:
- Medicare Physical Therapy: Self-Referring Providers Generally Referred More Beneficiaries but Fewer Services Per Beneficiary," GAO-14-270, April 2014 (released June 2014);
- "Medicare: Higher Use of Advanced Imaging Services by Providers Who Self-Refer Costing Medicare Millions," GAO 12-966, September 201;
- "Medicare: Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self Refer," GAO 13-445, June 2013; and
- "Medicare: Higher Use of Costly Prostate Cancer Treatment by Providers Who Self-Refer Warrants Scrutiny," GAO 13-525, July 2013.