Ownership of clinical laboratories by referring physicians: effects on utilization, charges, and profitability

Trends in Medically Integrated Dispensing Among Oncology Practices

PURPOSE

The integration of pharmacies with oncology practices-known as medically integrated dispensing or in-office dispensing-could improve care coordination but may incentivize overprescribing or inappropriate prescribing. Because little is known about this emerging phenomenon, we analyzed historical trends in medically integrated dispensing.

METHODS

Annual IQVIA data on oncologists were linked to 2010-2019 National Council for Prescription Drug Programs pharmacy data; data on commercially insured patients diagnosed with any of six common cancer types; and summary data on providers' Medicare billing. We calculated the national prevalence of medically integrated dispensing among community and hospital-based oncologists. We also analyzed the characteristics of the oncologists and patients affected by this care model.

RESULTS

Between 2010 and 2019, the percentage of oncologists in practices with medically integrated dispensing increased from 12.8% to 32.1%. The share of community oncologists in dispensing practices increased from 7.6% to 28.3%, whereas the share of hospital-based oncologists in dispensing practices increased from 18.3% to 33.4%. Rates of medically integrated dispensing varied considerably across states. Oncologists who dispensed had higher patient volumes (P < .001) and a smaller share of Medicare beneficiaries (P < .001) than physicians who did not dispense. Patients treated by dispensing oncologists had higher risk and comorbidity scores (P < .001) and lived in areas with a higher % Black population (P < .001) than patients treated by nondispensing oncologists.

CONCLUSION

Medically integrated dispensing has increased significantly among oncology practices over the past 10 years. The reach, clinical impact, and economic implications of medically integrated dispensing should be evaluated on an ongoing basis.

White paper: statement on conflicts of interest

INTRODUCTION

Conflicts of interest are a normal part of human social intercourse. They become problematic when there is a power differential between participants in the setting of relationships requiring a high degree of trust, as in healthcare. In this white paper we consider how these conflicts may be detected and mitigated.

METHODS

Following Medline search and reference chaining, we undertook a narrative review of the literature with iterative discussion.

RESULTS

Conflicts of interest may be financial, professional or personal, and may operate at the level of the individual or the organisation. Unmanaged, they become a source of bias which places the interests of the professional or the organisation before those of the patient. Reported with increasing frequency, conflicts damage trust, harm patients, and defraud the health system. We make 15 recommendations for minimising conflicts of interest.

CONCLUSIONS

Nationally funded open-access registries should be established to permit complete disclosure of financial, professional, and personal relationships with the potential for driving bias in research, clinical practice, or health management. Governance of disclosure should be the responsibility of employing organisations through annual staff appraisals, audited by national research integrity committees. Research fraud should incur suspension of the license to practice. Organisations should monitor staff perceptions of ethical climate to enhance awareness of staff behaviours and the potential for misconduct driven by academic pressures. Clear separation of advisory and voting roles is needed in best practice guideline panels. Professional societies and scientific journals should display conflict of interest policies for their own staff and officers as well as for speakers and authors. Undergraduates should not be exposed to pharmaceutical promotions masquerading as education. Undergraduate and postgraduate training programmes should include teaching about managing conflicts of interest and identifying research misconduct.

An unhealthy public-private tension: pharmacy ownership, prescribing, and spending in the Philippines

Physicians' links with pharmacies may create perverse financial incentives to overprescribe, prescribe products with higher profit margins, and direct patients to their pharmacy. Interviews with pharmacy customers in the Philippines show that those who use pharmacies linked to public-sector physicians had 5.4 greater odds of having a prescription from such physicians and spent 49.3 percent more than customers using other pharmacies. For customers purchasing brand-name medicines, switching to generics would reduce drug spending by 58 percent. Controlling out-of-pocket spending on drugs requires policies to control financial links between doctors and pharmacies, as well as tighter regulation of nongeneric prescribing.

Laboratory test ordering at physician offices with and without on-site laboratories

BACKGROUND

Physician self-referral, ordering a test or procedure or referring to a facility in which a physician has a financial interest, has been associated with increased utilization of health care services.

OBJECTIVE

To examine the association between on-site laboratories and laboratory test ordering among visits to group-practice physicians.

DESIGN

Cross-sectional study using data from the 2005 and 2006 National Ambulatory Medical Care Surveys.

STUDY POPULATION

Visits by adults to non-federally-funded, non-hospital-based group practices. Primary analyses focused on visits to physician owners; secondary analyses focused on visits to non-owners.

MAIN MEASURES

Ordering of five laboratory tests: complete blood count (CBC), electrolytes, glycoslyated hemoglobin A1c (HbA1c), cholesterol, and prostate-specific antigen (PSA).

KEY RESULTS

There were 19,163 visits to group-practice owners with 51.9% to a practice with an on-site laboratory. Visits to primary care physicians were more likely to be to a practice with an on-site laboratory when compared with visits to specialists (64.4% vs. 34.0%, p < 0.001). Among visits to specialist group owners, all five tests were ordered more often if there was an on-site laboratory, even after accounting for patient and practice characteristics: CBC: adjusted odds ratio[OR] = 8.01, 95% Confidence Interval [CI], 5.00-12.82, p < 0.001; electrolytes: aOR = 3.51, 95% CI, 1.93-6.40, p < 0.001; HbA1c: aOR = 4.91, 95% CI, 1.75-13.78, p = 0.003; cholesterol: aOR = 3.32, 95% CI, 1.85-5.93, p < 0.001; and PSA: aOR = 3.84, 95% CI, 1.93-7.65, p < 0.001. This association was not found among visits to primary care physician owners and all practice non-owners (both primary care and specialists). The estimated excess spending on these five tests by specialist owners with on-site laboratories was $75 million per 100 million visits.

CONCLUSIONS

In a nationally representative sample of visits to physician-owned group practices, specialist owners with on-site laboratories were more likely to order five common laboratory tests, potentially resulting in millions in excess healthcare spending.