http://query.nytimes.com/gst/fullpage.html?sec=health&res=950CE6DA1E3EF932A35751C1A9609C8B63
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Profit and Questions as Doctors Offer Prostate Cancer Therapy
By STEPHANIE SAUL
Published: December 1, 2006
The nearly 240,000 men in the United States who will learn they have prostate cancer this year have one more thing to worry about: Are their doctors making treatment decisions on the basis of money as much as medicine?
Among several widely used treatments for prostate cancer, one stands out for its profit potential. The approach, a radiation therapy known as I.M.R.T., can mean reimbursement of $47,000 or more a patient.
That is many times the fees that urologists make on other accepted treatments for the disease, which include surgery and radioactive seed implants. And it may help explain why urologists have started buying multimillion-dollar I.M.R.T. equipment and software, and why many more are investigating it as a way to increase their incomes.
Already, dozens of the nation's 10,000 urologists have purchased the technology for intensity modulated radiation therapy, which is what I.M.R.T. stands for, and some of them are recommending its use for growing numbers of their patients.
Critics see a potential conflict of interest on the part of urologists, the specialists who typically help prostate patients choose a course of treatment. The critics say that urologists who can profit from the new form of therapy may be less likely to recommend other proven approaches, which for some older men can involve forgoing treatment altogether.
If the patient has insurance, the added expense may not be a concern for him. And like the other treatments, the new therapy can be highly effective. But doctors say that prostate cancer treatments should be tailored to the individual.
Compared with seed implants, for example, I.M.R.T. involves a large time commitment, requiring patients to visit a radiation center 45 times over the course of nine weeks.
More worrisome for some experts is a concern that the multiple-beam radiation of I.M.R.T. may raise the risk of secondary cancers, although no medical studies have proved such a link.
Helping drive the trend is a Texas company, Urorad Healthcare, which sells complete packages of I.M.R.T. technology and services, and hopes to persuade even more urologists to buy them.
''Join the Urorad team and let us show your group how Urorad clients double their practice's revenue,'' the company says in a marketing pitch to doctors on its Web site.
Urologists who have purchased the new multiple beam systems say they are embracing a superior way to treat prostate cancer. But because there is little research directly comparing I.M.R.T. with the other treatments, there is little consensus among urologists about which approach is best.
That is why some doctors worry that I.M.R.T. may be emerging as yet another example of the way financial incentives can influence medical decisions in this nation's for-profit health care economy.
''It's all money-driven, and it's a shame medicine has come down to this,'' said Dr. Brian Moran, a radiation oncologist in Chicago, who specializes in radioactive-seed implants, in which tiny radioactive pellets are placed into the prostate. His clinic is paid $15,000 or less for the procedure, with the urologist on the case getting about $900.
Dr. Eli Glatstein, a professor of radiation oncology at the University of Pennsylvania, said he was concerned that some urologists would steer patients to the new treatment because they owned the technology and could greatly profit from its use.
''It's not illegal to do this,'' Dr. Glatstein said. ''That doesn't make it right.''
I.M.R.T. was introduced in the mid-1990s and has proved useful for delivering multiple beams of radiation to a small area while avoiding healthy tissue. Like other treatments for prostate cancer, though, it has possible side effects, potentially including impotence.
The one certainty about I.M.R.T. is that for doctors who own the technology, it can be much more lucrative than alternative treatments. Medicare and other insurers typically pay urologists only $2,000 or less for performing surgery to remove the prostate or for implanting radioactive seeds. The insurers say the much higher I.M.R.T. payments, which in some cases exceed $50,000, are based on the technology's cost.
Leslie Norwalk, Medicare's chief administrator, said she was not worried that doctors who invest in I.M.R.T. would use it on patients who require no treatment.
''You're just not going to do beam therapy on someone who doesn't need it,'' Ms. Norwalk said in a telephone interview.
But because of the potential conflicts, urologist-owned I.M.R.T. is the type of arrangement that Medicare should be watching, she said.
Dr. Juan A. Reyna, president of a San Antonio urology group that was among the first to order I.M.R.T. technology in 2004, said that the revenue opportunities were a factor in the decision to buy it.
''These are the kind of things you have to do to be able to maintain yourself in practice,'' Dr. Reyna said, noting that Medicare has been cutting back payments for other forms of prostate cancer treatment. Dr. Reyna says he recommends the treatment more frequently now because he is convinced of its value.
Some other urologists, though, say they are uncomfortable with the I.M.R.T. ownership trend. For example, Dr. Robert Waldbaum of Manhasset, N.Y., said he declined to go along when a large group of Long Island urologists invested in the technology, fearing it might influence his advice to patients.
''I felt in my own mind that it would be a conflict of interest to me,'' said Dr. Waldbaum, the former chairman of urology at North Shore University Hospital, who is in private practice.
Varian Medical Systems, a leading maker of the technology, still sells it mainly to hospitals and free-standing radiation oncology centers. But it has sold about 20 I.M.R.T.-capable machines to urology groups, according to a company spokesman, Spencer Sias. Typically, doctor groups pool their money to buy the technology.
''There's definitely heightened interest from urology practices in this,'' Mr. Sias said.
Helping drive that interest is Urorad, based in McAllen, Tex., which has been aggressively marketing I.M.R.T. to urologists across the country, who must either hire a radiation oncologist or form a partnership with one. The company helps arrange a complete setup as well as consulting services to calculate radiation doses for patients, with costs to get started estimated at about $3 million.
Five Urorad centers are already operating around the country, according to Dr. Mark L. Harrison, the chief executive, who said that contracts had been signed for six more.
The majority of prostate cancers are caught early, owing mainly to use of the prostate-specific antigen test. Still, prostate cancer is the second-leading cause of cancer-related deaths in men, after lung cancer.
The prostate cancers that are detected early have several treatment alternatives with high success rates -- among them surgery, radioactive seed implants, and external radiation, like the multiple beam therapy.
In some cases, especially for older men, doctors recommend ''watchful waiting,'' or no treatment at all. An estimated 40 percent to 50 percent of men with the disease get surgery, which many doctors still consider the gold standard for a cure. But surgery also carries a risk of incontinence; up to 29 percent of men who have their prostates removed report wearing pads to keep dry, according to one large study.
As with surgery and seed implants, men treated with I.M.R.T. run a risk of eventual impotence. A recent study at Memorial Sloan-Kettering Cancer Center, which has conducted much of the early research onthe therapy, found that eight years after treatment, 49 percent of men who were potent before treatment developed erectile dysfunction.
Compared with surgery, neither seed implants nor I.M.R.T. carry high risks of incontinence, though. And the arguments in favor of the multiple beam therapy include a new research study indicating that urinary complications, like painful urination and a narrowing of the urethra, are lower with I.M.R.T. than with seed implants.
Depending on the region of the country, the owner of an office-based I.M.R.T. system can be reimbursed up to $47,000 for a nine-week course of daily treatments, including the physician's fee, which often goes to the radiation oncologist.
Medicare and commercial insurers have said the reimbursements are based not only on the cost of the software and equipment, but on the complicated mathematical calculations required in administering the treatments.
Yet Dr. Ivan A. Brezovich, a physicist at the University of Alabama at Birmingham, said that delivering multiple beam therapy to the prostate was a relatively simple procedure compared with using it on more complex conditions like head and neck cancers.
''You can do it almost on an assembly-line basis,'' Dr. Brezovich said.
Medicare, which has reviewed the issue, is scheduled to begin reducing I.M.R.T. reimbursements. For example, reimbursement in the Atlanta area, considered close to the national median, is scheduled to be cut by 8.2 percent, from $39,000 this year to $35,800 in 2007.
But because Medicare or another insurer pays for the treatment, cost is often not a factor for patients as they assess their options.
Leonard Streim, 58, a clinical psychologist in Deer Park, N.Y., learned he had prostate cancer this year. He said he researched various options, including seed implants and surgery, before deciding on multiple beam treatment, which was covered by his medical insurance.
Mr. Streim said his side effects were minimal.
''As compared to surgery, as compared to walking around being radioactive, I don't think there's any choice there, at least not for me,'' he said.
His urologist is a member of a large Long Island group, Integrated Medical Professionals, formed in July by 13 different practices with a total of more than 30 doctors. Now the largest urology group on Long Island, it pooled its resources to invest in an image-guided I.M.R.T. system, which uses markers implanted in the prostate to more accurately direct the beams of radiation. Some say that the group's formation has contributed to a shift in prostate cancer treatment in the region.
Fewer patients in the area now appear to be getting seed implants, according to Dr. Jay Bosworth, a radiation oncologist involved with another Long Island group of diagnostic and treatment centers whose services include I.M.R.T.
According to three hospitals where doctors in the Integrated Medical Professionals group have practiced, about 300 seed procedures were performed in 2005 compared with about 100 this year through mid-October.
Dr. Deepak A. Kapoor, Integrated Medical's chief executive, said the downturn in seed implants began before his group's formation, as urologists began to recognize the benefits of I.M.R.T. He denied that financial incentives were a driving force.
''All of our physicians are required to discuss all available options with every patient,'' Dr. Kapoor said.
One of Dr. Kapoor's Long Island patients, Daniel Staiano of Massapequa, N.Y., who is covered by Medicare, said he was not concerned to learn that his urologist had a financial stake in the therapy.
Mr. Staiano, 75, was one of several patients treated by I.M.R.T. in Plainview, N.Y., who said they suffered only minor side effects after the nine-week course of radiation.
''This treatment is fabulous,'' said Mr. Staiano, a retired tape editor for NBC, who said that his side effects were minimal. ''If I ever get cancer again,'' he said, ''this is the way I want to go.''
Side Effects
Articles in this series are examining how monetary considerations can influence the ways doctors conduct business and practice medicine.
------------------------------------
Profit and Questions as Doctors Offer Prostate Cancer Therapy
By STEPHANIE SAUL
Published: December 1, 2006
The nearly 240,000 men in the United States who will learn they have prostate cancer this year have one more thing to worry about: Are their doctors making treatment decisions on the basis of money as much as medicine?
Among several widely used treatments for prostate cancer, one stands out for its profit potential. The approach, a radiation therapy known as I.M.R.T., can mean reimbursement of $47,000 or more a patient.
That is many times the fees that urologists make on other accepted treatments for the disease, which include surgery and radioactive seed implants. And it may help explain why urologists have started buying multimillion-dollar I.M.R.T. equipment and software, and why many more are investigating it as a way to increase their incomes.
Already, dozens of the nation's 10,000 urologists have purchased the technology for intensity modulated radiation therapy, which is what I.M.R.T. stands for, and some of them are recommending its use for growing numbers of their patients.
Critics see a potential conflict of interest on the part of urologists, the specialists who typically help prostate patients choose a course of treatment. The critics say that urologists who can profit from the new form of therapy may be less likely to recommend other proven approaches, which for some older men can involve forgoing treatment altogether.
If the patient has insurance, the added expense may not be a concern for him. And like the other treatments, the new therapy can be highly effective. But doctors say that prostate cancer treatments should be tailored to the individual.
Compared with seed implants, for example, I.M.R.T. involves a large time commitment, requiring patients to visit a radiation center 45 times over the course of nine weeks.
More worrisome for some experts is a concern that the multiple-beam radiation of I.M.R.T. may raise the risk of secondary cancers, although no medical studies have proved such a link.
Helping drive the trend is a Texas company, Urorad Healthcare, which sells complete packages of I.M.R.T. technology and services, and hopes to persuade even more urologists to buy them.
''Join the Urorad team and let us show your group how Urorad clients double their practice's revenue,'' the company says in a marketing pitch to doctors on its Web site.
Urologists who have purchased the new multiple beam systems say they are embracing a superior way to treat prostate cancer. But because there is little research directly comparing I.M.R.T. with the other treatments, there is little consensus among urologists about which approach is best.
That is why some doctors worry that I.M.R.T. may be emerging as yet another example of the way financial incentives can influence medical decisions in this nation's for-profit health care economy.
''It's all money-driven, and it's a shame medicine has come down to this,'' said Dr. Brian Moran, a radiation oncologist in Chicago, who specializes in radioactive-seed implants, in which tiny radioactive pellets are placed into the prostate. His clinic is paid $15,000 or less for the procedure, with the urologist on the case getting about $900.
Dr. Eli Glatstein, a professor of radiation oncology at the University of Pennsylvania, said he was concerned that some urologists would steer patients to the new treatment because they owned the technology and could greatly profit from its use.
''It's not illegal to do this,'' Dr. Glatstein said. ''That doesn't make it right.''
I.M.R.T. was introduced in the mid-1990s and has proved useful for delivering multiple beams of radiation to a small area while avoiding healthy tissue. Like other treatments for prostate cancer, though, it has possible side effects, potentially including impotence.
The one certainty about I.M.R.T. is that for doctors who own the technology, it can be much more lucrative than alternative treatments. Medicare and other insurers typically pay urologists only $2,000 or less for performing surgery to remove the prostate or for implanting radioactive seeds. The insurers say the much higher I.M.R.T. payments, which in some cases exceed $50,000, are based on the technology's cost.
Leslie Norwalk, Medicare's chief administrator, said she was not worried that doctors who invest in I.M.R.T. would use it on patients who require no treatment.
''You're just not going to do beam therapy on someone who doesn't need it,'' Ms. Norwalk said in a telephone interview.
But because of the potential conflicts, urologist-owned I.M.R.T. is the type of arrangement that Medicare should be watching, she said.
Dr. Juan A. Reyna, president of a San Antonio urology group that was among the first to order I.M.R.T. technology in 2004, said that the revenue opportunities were a factor in the decision to buy it.
''These are the kind of things you have to do to be able to maintain yourself in practice,'' Dr. Reyna said, noting that Medicare has been cutting back payments for other forms of prostate cancer treatment. Dr. Reyna says he recommends the treatment more frequently now because he is convinced of its value.
Some other urologists, though, say they are uncomfortable with the I.M.R.T. ownership trend. For example, Dr. Robert Waldbaum of Manhasset, N.Y., said he declined to go along when a large group of Long Island urologists invested in the technology, fearing it might influence his advice to patients.
''I felt in my own mind that it would be a conflict of interest to me,'' said Dr. Waldbaum, the former chairman of urology at North Shore University Hospital, who is in private practice.
Varian Medical Systems, a leading maker of the technology, still sells it mainly to hospitals and free-standing radiation oncology centers. But it has sold about 20 I.M.R.T.-capable machines to urology groups, according to a company spokesman, Spencer Sias. Typically, doctor groups pool their money to buy the technology.
''There's definitely heightened interest from urology practices in this,'' Mr. Sias said.
Helping drive that interest is Urorad, based in McAllen, Tex., which has been aggressively marketing I.M.R.T. to urologists across the country, who must either hire a radiation oncologist or form a partnership with one. The company helps arrange a complete setup as well as consulting services to calculate radiation doses for patients, with costs to get started estimated at about $3 million.
Five Urorad centers are already operating around the country, according to Dr. Mark L. Harrison, the chief executive, who said that contracts had been signed for six more.
The majority of prostate cancers are caught early, owing mainly to use of the prostate-specific antigen test. Still, prostate cancer is the second-leading cause of cancer-related deaths in men, after lung cancer.
The prostate cancers that are detected early have several treatment alternatives with high success rates -- among them surgery, radioactive seed implants, and external radiation, like the multiple beam therapy.
In some cases, especially for older men, doctors recommend ''watchful waiting,'' or no treatment at all. An estimated 40 percent to 50 percent of men with the disease get surgery, which many doctors still consider the gold standard for a cure. But surgery also carries a risk of incontinence; up to 29 percent of men who have their prostates removed report wearing pads to keep dry, according to one large study.
As with surgery and seed implants, men treated with I.M.R.T. run a risk of eventual impotence. A recent study at Memorial Sloan-Kettering Cancer Center, which has conducted much of the early research onthe therapy, found that eight years after treatment, 49 percent of men who were potent before treatment developed erectile dysfunction.
Compared with surgery, neither seed implants nor I.M.R.T. carry high risks of incontinence, though. And the arguments in favor of the multiple beam therapy include a new research study indicating that urinary complications, like painful urination and a narrowing of the urethra, are lower with I.M.R.T. than with seed implants.
Depending on the region of the country, the owner of an office-based I.M.R.T. system can be reimbursed up to $47,000 for a nine-week course of daily treatments, including the physician's fee, which often goes to the radiation oncologist.
Medicare and commercial insurers have said the reimbursements are based not only on the cost of the software and equipment, but on the complicated mathematical calculations required in administering the treatments.
Yet Dr. Ivan A. Brezovich, a physicist at the University of Alabama at Birmingham, said that delivering multiple beam therapy to the prostate was a relatively simple procedure compared with using it on more complex conditions like head and neck cancers.
''You can do it almost on an assembly-line basis,'' Dr. Brezovich said.
Medicare, which has reviewed the issue, is scheduled to begin reducing I.M.R.T. reimbursements. For example, reimbursement in the Atlanta area, considered close to the national median, is scheduled to be cut by 8.2 percent, from $39,000 this year to $35,800 in 2007.
But because Medicare or another insurer pays for the treatment, cost is often not a factor for patients as they assess their options.
Leonard Streim, 58, a clinical psychologist in Deer Park, N.Y., learned he had prostate cancer this year. He said he researched various options, including seed implants and surgery, before deciding on multiple beam treatment, which was covered by his medical insurance.
Mr. Streim said his side effects were minimal.
''As compared to surgery, as compared to walking around being radioactive, I don't think there's any choice there, at least not for me,'' he said.
His urologist is a member of a large Long Island group, Integrated Medical Professionals, formed in July by 13 different practices with a total of more than 30 doctors. Now the largest urology group on Long Island, it pooled its resources to invest in an image-guided I.M.R.T. system, which uses markers implanted in the prostate to more accurately direct the beams of radiation. Some say that the group's formation has contributed to a shift in prostate cancer treatment in the region.
Fewer patients in the area now appear to be getting seed implants, according to Dr. Jay Bosworth, a radiation oncologist involved with another Long Island group of diagnostic and treatment centers whose services include I.M.R.T.
According to three hospitals where doctors in the Integrated Medical Professionals group have practiced, about 300 seed procedures were performed in 2005 compared with about 100 this year through mid-October.
Dr. Deepak A. Kapoor, Integrated Medical's chief executive, said the downturn in seed implants began before his group's formation, as urologists began to recognize the benefits of I.M.R.T. He denied that financial incentives were a driving force.
''All of our physicians are required to discuss all available options with every patient,'' Dr. Kapoor said.
One of Dr. Kapoor's Long Island patients, Daniel Staiano of Massapequa, N.Y., who is covered by Medicare, said he was not concerned to learn that his urologist had a financial stake in the therapy.
Mr. Staiano, 75, was one of several patients treated by I.M.R.T. in Plainview, N.Y., who said they suffered only minor side effects after the nine-week course of radiation.
''This treatment is fabulous,'' said Mr. Staiano, a retired tape editor for NBC, who said that his side effects were minimal. ''If I ever get cancer again,'' he said, ''this is the way I want to go.''
Side Effects
Articles in this series are examining how monetary considerations can influence the ways doctors conduct business and practice medicine.
