Our results indicate that more than half of Texas residents live within 10 miles of an integrated urology-RO practice and more than one quarter of the urologists in the state work in such practices. These findings suggest that urologist-owned radiation therapy facilities are a meaningful contributor to cancer treatment delivery in the state. However, this contribution is limited to densely populated urban areas, as shown in and , and does not appear to improve access to radiation therapy for the rural population.
Additionally, our data reveal that in the state of Texas, integrated urology-RO practices may be administratively integrated but usually are not physically integrated, meaning that urology and RO services are rarely offered at the same physical address. The extent to which this lack of physical integration has the potential to mitigate the purported benefits of integrated prostate cancer care models (2
) requires further research. Our data also indicate that patients diagnosed with prostate cancer at an integrated urology clinic would have to drive substantially farther to reach the integrated RO facility than they would to reach the nearest nonintegrated RO clinic. The potential effect of increased patient driving times on the perceived convenience of care merits further study; this is particularly important for a treatment such as radiation therapy for prostate cancer, which often entails more than 8 weeks of daily treatment.
Since the inception of a specific Medicare current procedural terminology code for intensity-modulated radiation therapy (IMRT), the use of this treatment modality has increased substantially. Currently, approximately one in three Medicare beneficiaries with prostate cancer is treated with IMRT (10
). IMRT has been reimbursed at three to four times the rate of other treatment options for prostate cancer, including radical prostatectomy, interstitial brachytherapy, and active surveillance.
Additionally, radiation therapy falls under the in-office ancillary services exception of the Stark self-referral law. As a result, at least 37 urology groups nationally have obtained their own linear accelerator and started referring their patients with prostate cancer to their own radiation treatment center (9
). Critics of the integrated urology-RO practice model state that it creates financial incentives for urologists to recommend IMRT over other less expensive treatment options, particularly active surveillance (1
). This financial incentive and its effect on practice patterns and possible overutilization of IMRT are currently being investigated by the US Government Accountability Office as well as a number of state governments (4
However, there are various arguments that support the integrated urology-RO practice model. Proponents state that integrated practices offer patients convenient access to experts in all treatment options for prostate cancer (10
). Additionally, though IMRT use has increased with the advent of integrated urology-RO practices, an argument can be made that advances in radiation therapy delivery and treatment have made radiation therapy a more attractive option for most patients with prostate cancer, independent of their seeking care at urologist-owned radiation therapy practices (3
Texas is a vanguard state in which to examine this phenomenon; since 2004 one of the pioneering companies that helped urology practices acquire radiation services has been headquartered in the state (12
). In the intervening years, the number of urologists participating in these integrated clinics has expanded considerably; currently nearly 30% of urologists licensed in Texas are invested in a radiation therapy linear accelerator. Texas and other states in which this type of practice has flourished do not require a certificate of need to open a radiation therapy center. Certificate-of-need laws, which have been adopted in 36 states that we know of, restrict ownership of linear accelerators by requiring state approval before the purchase of equipment or construction of a health care facility (13
). As reported by the Government Accountability Office, the presence of these restrictions is associated with a decrease in specialty integrated hospitals (14
) and likely has the same effect on the prevalence of integrated clinics.
This study is limited in that only practice arrangements in Texas are considered. It is quite possible that in a state with a smaller geographic area and a higher population density, the difference between the travel times to the nearest integrated RO treatment facility and to the nearest nonintegrated RO clinic would be less. Additionally, the evaluation of rural access in this study is based on qualitative visual inspection of the geographic distribution. Further, although the integrated urology-RO practice structure may offer other unique advantages, such as integration of medical records or unified billing, our study was not designed to quantify these features.
Another limitation of this study is that it was not designed to identify or be applied to more subtle practice arrangements, which can include urologist investment, along with other physicians, in a multispecialty hospital that includes radiation services or in a radiation treatment center that is co-owned by a radiation oncologist. Such arrangements are known to occur, but are often opaque and thus difficult to identify with certainty. Finally, our survey was limited in that only practices with four or more urologists were contacted. Although it is possible that small urology practices may also offer integrated RO services, we cross-checked our survey findings with a complete list of linear accelerators in the state of Texas. After examining each linear accelerator’s record, we did not identify any small urology practices in explicit possession of a linear accelerator.
In summary, this is the first study to evaluate the prevalence and geographical structure of integrated urology-RO practices in Texas. Most of these practices are clustered in urban areas with high population density, and the urology and RO clinics usually are not physically integrated in the same geographical location. Future studies are needed to determine how this new practice model affects prostate cancer care patterns, quality, and patient satisfaction.