AADA questions GAO report

The American Academy of Dermatology Association (AADA) and the Government Accountability Office (GAO) remain at odds over the GAO’s recommendation that Medicare payments limit financial incentives for self-referral of biopsies.

In early 2013, the GAO gave the AADA a draft version of a report titled “Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer (GAO-13-445).” According to AAD Board of Directors member Jane M. Grant-Kels, M.D., the AADA delegation to the GAO told the GAO that the report is inaccurate because it did the following:

• Lumped together gastrointestinal, genitourinary and dermatology data to calculate final numbers (even though in tables, the report authors broke out dermatology).

• Excluded all physicians who did the professional component (PC) only.

• Misclassified physicians who both referred out and read their own biopsy specimens as self-referring;

• Used taxpayer identification numbers (TINs) for tracking referrals. “This creates problems because for very large hospital and university faculty groups, this would have misclassified people who refer as ‘self-referrals.’ There is no financial incentive for faculty who are salaried” to do this, Dr. Grant-Kels says.

• Did not obtain standard deviations on number of biopsies per patient.

• Failed to consider variation on biopsies per patient within practices and across practices. “We don’t know if confidence intervals overlap between self-referrals and non-self-referrals. The report did not assess the overlap between variation within practice and between practices,” she says.

• Did not consider possible practice growth in tracking biopsy totals of physicians who switched to self-referral. “This could possibly account for growth in biopsies.”

• Failed to couch results in context of the 2009 Centers for Medicare & Medicaid Services anti-markup rules, which could have impacted rate of switchers in the year tested.

• Gave insufficient demographic information about respondents. “And specifically,” Dr. Grant-Kels says, “the report did not give us breakdowns by geographic area (only rural versus metropolitan), sub-specialization and years in practice/age of practitioners.”

• Did not account for physician extenders like nurses and physician assistants who also bill under the physician’s National Provider Identifier (NPI) in incident-to situations.

• Confused common practice of urology with dermatology in terms of how specimens should be submitted. “Appropriate dermatology practice requires that specimens be submitted in separate bottles,” Dr. Grant-Kels says. “The physician has no choice but to separate these specimens. Bundling specimens (as done in urology) is inappropriate and impractical in dermatology. Multiple biopsies have a built-in disincentive due to reduced rates to the clinician.”

GAO response

The GAO addressed several of these concerns in the report’s final version, released in June 2013. For example, the report states, “The increase in anatomic pathology referrals for providers that began self-referring in 2009 cannot be explained exclusively by factors such as providers joining larger practices with higher patient volumes, different patient populations or different practice cultures.”

Providers who stayed in the same practice from 2007 through 2010, but began self-referring in 2009, had a bigger increase in the number of anatomic pathology services referred than providers who did not start performing in-house dermatopathology, the report adds.

Subsequently, the AADA released a statement reiterating its concerns over methodological flaws in the report (http://www.aad.org/stories-and-news/news-releases/academy-statement-on-gao-report-on-in-office-pathology-services).

While the AADA recognizes the value of integration of care for patients, the statement concludes, “The AADA also believes it is important to preserve the ability of dermatologists to read their own pathology slides consistent with their training and will work to ensure that this right is exercised appropriately.” At press time, the GAO had not responded to this statement.

Disclosures: Dr. Grant-Kels is professor and chairman of dermatology, University of Connecticut School of Medicine. She also directs the department’s dermatopathology service, residency program and cutaneous oncology center. She is a member of the AAD Board of Directors. She reports no relevant financial interests.