Doctors' rationale for antitrust exception under fire

Lawmakers will get briefed on the touchy subject of physicians' exception from antitrust laws when the House Energy and Commerce health subcommittee takes up Medicare payment reform Wednesday afternoon. The panel holds a hearing with Glenn Hackbarth, chairman of the Medicare Payment Advisory Commission (MedPAC), on the commission's June report to Congress regarding proposals to get Medicare to pay for quality — rather than quantity — of care.

Hackbarth is scheduled to discuss the effects of the new healthcare reform law on Medicare and discuss further changes to the law that may be needed to give Medicare the flexibility it needs to change how it pays doctors and hospitals. One of the items up for discussion includes doctors' "in-office" exception from Rep. Pete Stark's (D-Calif.) Ethics in Patient Referrals Act, which prohibits physicians from referring Medicare patients to entities with which they have a financial relationship.

Many Democrats and healthcare experts say doctors who own scans and other such devices sometimes order extra imaging, laboratory and other tests that don't improve patients' health in order to make extra money. One of the rationales for the exception is that it enables physicians to make rapid diagnoses and initiate treatment during a patient's office visit, but MedPAC analyzed claims data for its new report and found that half or less of imaging, clinical laboratory and pathology services are performed on the same day as an office visit.

While the report does not make any recommendations, it explores several options, including: 

• Excluding outpatient therapy and radiation therapy from the exception;

• Limiting the exception to physician practices that are clinically integrated;

• Excluding diagnostic tests that are not usually provided during an office visit from the exception;

• Reducing payment rates for diagnostic tests performed under the exception;

• Improving payment accuracy and creating bundled payments; and

• Adopting prior authorization for imaging services.