Although there are anti-kickback laws that prohibit physician self-referrals, certain procedures are exempted from these statutes. For example, a urologist may refer patients to centers for lithotripsy (breaking up of urinary stones) even if s/he is invested in the center and therefore stands to profit from patient referral. This study used Florida’s Ambulatory Surgery Database to examine how 1,498 urologists’ use of surgery centers varied by penetration of owners within the local market. Florida has a high prevalence of patients with urinary stones, and does not tightly regulate competition between hospitals and free-standing ambulatory centers for this type of procedure.

Key Findings:

• Analysis showed a significant association between ownership of ambulatory centers (ASCs) and higher use of surgical services.
• Urologists who were owners of ASCs performed more of their surgeries in ASCs than urologists who were not owners (39.6 versus 8%).
• Owners of ASCs averaged 16.32 more cases annually than nonowners.

The authors note that their study does not prove that this association is causal. For example, owners of ASCs may have practices tailored toward surgical treatment of urinary stones, and thus their caseload for these procedures would be higher. Another explanation is that physicians who refer patients frequently to ASCs may become owners because they believe in the value and lower cost that ambulatory clinics can offer for this service compared to hospitals. Although this study had several limitations, such as the fact that certain procedures, i.e.,lithotripsy, were used as proxies for frequency of surgery use, the authors’ finding of an association between clinic ownership and utilization of clinic services remains robust. It is impossible to dismiss the possibility that financial motivation may contribute to the association detected in this study.