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is a perception that nancial arrangements between urologists who
advise patients on the treatment of prostate cancer, and the ability
of physicians to self-refer to sites where they maintain ownership
interests, is driving excess use.
4
The problem is that CMS has little ability to extend more
regulation over these nancial arrangements in the absence of
new statutory authority. So it has chosen to use the only instru-
ment under its direct controlits purview over setting pay-
ment ratesas a way to try and take some of the protability
out of these arrangements.
Some observers celebrate these ad hoc attempts by CMS to
tamp down on spending. As stewards of public spending, it falls
to the agency staff to police what they perceive as nancial waste
in health care. Or so the rationale goes.
But there is a corollary to these practices. By using imprecise
tools and relying on often-arbitrary rationales in targeting specic
services and procedures, CMS risks unintended consequences that
can adversely affect patient care. These risks are made more man-
ifest by the remote relationship between the agency and the prac-
tice of medicine.
In the case of radiation services, even if CMS is correct in its
apparent assumption that nancial ownership in these facilities
invites waste, its policy prescription falls short. If the physician-
owned clinics are really overusing these services (and, in turn,
earning excessive prots), then these might be the only facilities
with enough nancial cushion to survive a shakeout from a
broad payment change by the agency.
Provisions in the Affordable Care Act (ACA) can almost
ensure that we will see more of these sorts of policy journeys,
more imprecision, and more unintended harms. The ACAgives
CMS unilateral authority to tweak mispriced codes. It is a con-
struct that is not well dened. It is meant to include areas of
excess and inappropriate use. But CMS has never established
the kind of transparent and consistent procedures that could
bring precision to how it implements these provisions.
What is the alternative to allowing the agency to continue on
these sorts of excursions? It is to bind CMS to a rigorous meth-
odology where its activities to identify areas for savings are
grounded in a transparent and bottoms-up process, one that
relies on rigorous data. The FDA has established, over time, a
largely predictable and transparent method for how it goes
about making its evaluations. CMS, by comparison, is not gov-
erned by any similar discipline.
Alternatively, the task of mediating among competing ap-
proaches to care could be left to private payers, enlisted by
patients to set coverage and payment policies. This is how the
Medicare Advantage program is largely governed.
There are a lot of challenges when it comes to our current
payment systems in health care. However, it is unlikely that the
Medicare agency, acting on its own prerogatives, is going to
solve these problems through indiscriminate tactics.
Authors Disclosures of Potential Conicts of Interest
Although all authors completed the disclosure declaration, the following
author(s) and/or an authors immediate family member(s) indicated a
nancial or other interest that is relevant to the subject matter under
consideration in this article. Certain relationships marked with a U are
those for which no compensation was received; those relationships
marked with a C were compensated. For a detailed description of the
disclosure categories, or for more information about ASCOs conict of
interest policy, please refer to the Author Disclosure Declaration and the
Disclosures of Potential Conicts of Interest section in Information for
Contributors.
Employment or Leadership Position: Scott Gottlieb, Avalere Health
(C) Consultant or Advisory Role: Scott Gottlieb, GlaxoSmithKline (C),
American Pathology Partners (C) Stock Ownership: None Honoraria:
None Research Funding: None Expert Testimony: None Patents,
Royalties, and Licenses: None Other Remuneration: None
Corresponding author: Scott Gottlieb, XXXX, American Enterprise Insti-
tute for Public Policy Research, 1150 17th St NW, Washington, DC
20036; e-mail: scott.gottlieb@aei.org.
DOI: 10.1200/JOP.2013.001233
References
1. Gottlieb S: How the US Government rations health care. Wall Street Journal,
September 30, 2009:A1
2. Conway L: Proposed MPFS and HOPPS rules for 2013 contain signicant
changes for cancer providers. http://www.advisory.com/Research/Oncology-
Roundtable/Oncology-Rounds/2012/07/Proposed-MPFS-and-HOPPS-rules-
for-2013-contain-signicant-changes-for-cancer-providers
3. Falit BP, Dosoretz AP, Brennan TA: Ensuring accuracy within the Medicare
physician fee schedule: An example fromradiation oncology. J Oncol Pract [epub
ahead of print on October 8, 2013]
4. Mitchell JM: Urologists use of intensity-modulated radiation therapy for pros-
tate cancer. The N Engl J Med 369:1629-1637, 2013
2 JOURNAL OF ONCOLOGY PRACTI CE VOL. XX, I SSUE XX Copyright 2014 by American Society of Clinical Oncology
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