Beware the beam

by on August 19, 2013 at 4:44 am in Economics, Medicine | Permalink

Urologists “referred a substantially higher percentage of their prostate cancer patients” to radiation therapy when the doctors owned the equipment — linear accelerators — or had financial ties to those who provided the treatment, the report said.

Here is much more.

1 Frederic Mari August 19, 2013 at 5:33 am

Welcome to “patient’s choice”… 🙂

2 Frederic Mari August 19, 2013 at 5:34 am

Welcome to Patient’s choice… 🙂

(Google Patient’s Choice and NHS if you do not get the joke)

3 david August 19, 2013 at 6:14 am

Urologists who believe in the effectiveness of radiation therapy more liable to own the equipment to do so, or acquire financial ties to those providing the treatment?

4 Andrew' August 19, 2013 at 10:10 am

And/or they are more aware of it.

As I’ve said before, I’ve been on a search for someone who does partial tonsillectomy for adults and it’s a lost cause despite it being a superior technique supported by a few different proprietary technologies.

5 Steve August 19, 2013 at 7:58 am

You can pay an economist to justify anything. What is the economic plus-side of these extra treatments?

6 albert magnus August 19, 2013 at 8:46 am

Radiation oncology and radiology are the cash cows of hospitals. The reimbursements are way higher than the cost to perform the procedure. They are run like factories and require a low doctor/patient ratio.

Prostate cancer is a slow growing cancer that occurs to mostly elderly men, so its hard to show different treatments work better than others.

7 Z August 19, 2013 at 9:44 am

Perhaps I’m just a cynic, but I suspect we will see a flood of “reports” from the state claiming that effective, but costly, treatments are unnecessary. The irony is the state will end up doing exactly what they said insurance companies were doing. That is, acting out of self-interest rather than in the interests of the patient. It will be pitched as a social good, but that’s to be expected.

8 mark August 19, 2013 at 11:19 am

Well said, but the counter is that there is enough economic self-interest among providers ( unless we go down the single payer route) to generate competing research and analysis. So as long as we retain diversity in health care provision and payment mechanisms, the truth should eventually win out. If we go into a monopoly regime, it will get crushed.

Fwiw, my uncle regrets deeply his choice of radiation to address his PC. It destroyed a great deal of tissue and has made his elderly years miserable.

9 Z August 19, 2013 at 12:46 pm

Given that we don’t have a market for health care, I tend think it is pointless to apply market logic to anything to with human health care. Competition amongst rent seekers for opportunities to tax the people is competition, just not one that lends itself to market analysis. In this case, we know have the state with a strong incentive to deny treatment. I fully expect a rash of “studies” in support of letting grandpa die with dignity. Hilariously, the same people who have spent a career attacking insurance companies for such practices will be celebrating these new claims.

10 Therapsid August 19, 2013 at 11:21 am

I agree, but why are economists across the spectrum endorsing this line? Is it in their self-interest too?

11 FC August 20, 2013 at 1:04 am

Who do you think the state will hire to tell physicians how to do medicine? Economists, of course.

12 student August 19, 2013 at 10:24 am

For the curious, there is a substantive empirical literature on excessive referrals of this type. A Google search for something like “physician referral ancillary facilities ownership” (without quotation marks) should do it.

13 Andrew' August 19, 2013 at 1:02 pm

That’s great. No snark. But do they control for everything?

For example “Urologists “referred a substantially higher percentage of their prostate cancer patients” to radiation therapy” is a laden sentence.

Do the others refer traditional surgery that might cause more negative side effects?

14 student August 19, 2013 at 6:52 pm

The identification isn’t watertight, but the literature as a whole and conversations with physicians are enough to make me think self-referral likely increases spending. There is a paper by Afendulis and Kessler (2007?) that analyzes choices in interventional cardiology (medical management vs procedures) when the diagnoser can provide both services. The results aren’t encouraging.

15 student August 19, 2013 at 6:57 pm

Though not on organizations, Otis Webb Brawley’s book *How We Do Harm* provides strong anecdotal evidence that physicians certainly respond to financial incentives. He gives a front-libe report from oncology.

16 Simul Parikh, M.D. August 19, 2013 at 11:03 am

There is a group that practices in Maryland outside of state law, which clearly indicates that this is illegal. But, since Federal law doesn’t restrict it yet, they continue to practice and violate the laws.

The Wall Street Journal has written about urologists extensively in the past, as well:

I think it’s terrible, but what can you do? When the incentives are aligned as such, people work in financial self interest?

17 Yancey Ward August 19, 2013 at 11:04 am


18 eddie August 19, 2013 at 1:32 pm

How many sound engineers does it take to change a light bulb?

One… two… three…

19 Doug M August 19, 2013 at 11:08 am

Suppose the Dead President Memorial Hospital acquires an expensive piece of equipment, and we look at one urologist in this hospital.

Patients will be referred to Dead Presidents because they have this equipment, and doctors there will see the results of patients treated with this new procedure. It would be reasonable to expect that the doctors who have first hand experience will be more impressed, than those who only know of the procedure via journals, conferences or word of mouth.

20 Eric August 19, 2013 at 11:55 am

If I ever make it to the top 0.1%, I think I will create a “Dead President Memorial Hospital”

21 Kevin August 19, 2013 at 12:45 pm

This really isn’t news at all. It’s been well known for some time that physicians consciously or unconsciously self refer to their own facilities or towards their own expertise. For example, there is no physician who doesn’t value the data from routine blood work, yet in doctor’s offices where the doctor has their own lab they will still order far more blood tests.

In a similar vein, it was found decades ago that if someone with carotid artery disease was referred by their primary care physician to a surgeon, they almost always were recommended for surgery, and if they were referred to a neurologist they were usually treated with anti-platelet meds. It was clear enough that the latter was equally effective, vastly safer, and vastly cheaper, but it was only after a huge study was done revealing the extent of the bias and the extent of the morbidity and mortality from the unnecessary surgeries did the most conservative treatment really take hold.

22 mavery August 19, 2013 at 1:03 pm

Yeah, isn’t this common knowledge? I remember reading reports on this like 8 years ago.

23 TWC August 19, 2013 at 1:37 pm

I noticed this post is tagged “Economics, Medicine”. In addition, you could add, “Behavioral Science, Law of Instrument”.

24 Thor August 19, 2013 at 4:44 pm


So true…

25 JWatts August 19, 2013 at 6:57 pm

“I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” Abraham Maslow

26 Floccina August 23, 2013 at 3:27 pm

1. Not to defend Doctors, but if I am a big believer in radiation therapy and or the latest technology I am more likely to buy radiation therapy equipment.

2. I think that there would be less of this if Doctors knew their patients were paying out of pockets. Even Doctors (above average citizens though they might be) do not care about insurance company or Government money but they do seem to care about their patents money.

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