To the Editor:

I am troubled by the example in Alice Gosfield’s “The Stark Truth About the Stark Law: Part I” [November/December 2003, page 27] that describes the family physician whose husband is a pathologist. Even if her referrals do violate the law, is it likely they would be prosecuted? Let’s say she is in the only family medicine group in town and her husband works at the only group that performs hospital laboratory services within a 100-mile radius. What about a family physician whose wife is a physician employee of the local hospital ED to which he sends patients? Does this violate the law?

It seems that with more and more physician couples, such situations must occur all the time. Who better to refer your patients to than the physician you married? In no other person will you have as much trust and confidence that the medical service you need carried out will be accomplished. A law this confusing benefits no one, least of all our patients who entrust us with their lives.

Author’s response:

The issue of referrals between spouses for designated health services (DHS) under Stark is extremely problematic in this day of dual professional families. Because any referrals by a physician or immediate family member to an entity with which the physician or family member has a financial relationship could be implicated, the regulators have acknowledged the problems associated with these circumstances. The regulators explicitly believe that referrals to a spouse should be allowed if the Stark service is not the specific reason for the referral. For example, if the family physician refers a patient to his wife’s cardiology practice for treatment of a heart condition and the cardiology group does an echocardiogram, that’s a DHS but not a problem under the regulations. Additional comments may be made regarding this issue in the Phase II Stark regulations, which were expected last summer but have not yet been published.