Over the Thanksgiving holiday, I had the opportunity to spend time with my immediate family in Ohio. My older brother, Bob, informed me that after more than 30 years of practicing general urology, the first few years with our father in Marion, he is closing down shop next spring. Never one to mince words, Bob said it was time to move on. He still enjoys the patient interaction and the challenges of surgery, but the everyday hassles of dealing with insurance companies, mounting regulatory hurdles, and—as we can all relate&mdash; hospital calls overshadow the joy of clinical medicine. Time for a new chapter, a new hobby, and to enjoy waking up in the morning, and not dreading engaging with electronic health records. His new outlook is: What can I learn today?

A professor in medical school told me that if I learned 1 new fact from every patient that I ever encountered, medicine would always stay interesting and keep me engaged. Unfortunately, all of us lose focus and as the demands of the business side mount, we often forget what brought us to this great field.

As a teenager growing up in central Ohio, my father, my earliest physician mentor, told me that the greatest thing about being a doctor is that you pretty much work for yourself and set your own hours, but have to own your successes and failures. For decades, that has been true and was a very simplistic formula. However, survival of the independent physician is in question. The community urology world has been very successful in integrating services that facilitate better patient care, increase efficiencies, and reduce costs relative to the same services provided in a hospital setting.

Because of this vertical integration, this has allowed us to maintain economic stability in the face of diminishing reimbursement for professional services. However, the approval of the Medicare Access and CHIP Reauthorization Act in April 2015 moves us down the road of transition from volume to value-based medical payments. Yes, it did repeal the much despised Sustainable Growth Rate formula, but now, rightfully so, places emphasis on quality, resource utilization, advancing care, and practice improvement. As this becomes fully implemented over the next few years, along with certain aspects of the Affordable Care Act, seeing more patients without regard to better outcomes and metrics will not necessarily result in sustained/increasing revenue.

We have to do better for our patients, not just say we do. As a result of all the changes at the state and federal level in this environment of budget neutrality and cuts, many large independent urology groups across the United States find themselves struggling during this period of transition. A new ownership model has now surfaced and there is a burgeoning interest of private equity firms entering the urology space. As my dad stated over 40 years ago, there is still a fierce desire among urologists to stay independent and not be owned or employed by an integrated system. These new joint ventures may offer an alternative to independent community urologists, rather than selling to their local hospital system or just getting out of the business in general. However, as a specialty, we do have to evaluate the long-term viability of these models.

According to the presentation at the annual Large Urology Group Practice Association (LUGPA) meeting this past November in Chicago, Illinois, speakers advised that the traditional fee for service is not somehow going to be revived. The proverbial train has left the station, heading down the rails of value-based care. As we have done in the past, we need to understand the nuances and figure out how to survive and take advantage of the opportunity that is presenting itself to us.

As we close the curtain on 2017, we certainly have enjoyed a number of breakthroughs in urologic oncology care, as well as a better understanding of the important genetic component that we will all need to embrace, not only for patient management, but also for family counseling. I suspect we will see more advances and approvals in 2018, especially with the rapid proliferation of genetic testing and biomolecular imaging that will hopefully help to guide us more precisely in determining therapy for each patient.

With that being said, I wish all of you a very happy holiday season and a prosperous New Year. And to my older brother, Bob, I wish you nothing but continued success and happiness once you step away from this great field that we have been fortunate to have been a part of over the past few decades.

Articles

Because of vertical integration, this has allowed us to maintain economic stability in the face of diminishing reimbursement for professional services.

Reflecting Back, Looking Forward in Urology Practice

To the best of its ability, Associated Medical Professionals (AMP) of New York, a urology and radiation oncology practice, seeks to give its physician partners an equal share of its financial success while rewarding all staff members according to their levels of responsibility and workflow intensity.

“Finding a solution to make it fair and equitable to all partners is very difficult, especially when there are different referral patterns, geographic areas that have different insurance payers, or simply various specialists in the group,” said Christopher Williamson, chief operating officer.

AMP strives to achieve high standards of quality and motivated employees who commit to making a strong contribution in whatever area of skill and expertise is theirs. “From a business point of view, we want to reward the hard workers that are on the extreme side of productivity or those other physicians that perform the complicated cases, but at the same time those physicians who are in the trenches on a daily basis,” Williamson said. “Every single provider and staff member works together to provide the best care for our patients and achieve financial success for the group.”

AMP now has roughly 30 physicians and 10 clinical locations in 8 counties east of Lake Ontario and Lake Erie. The physicians attend at 9 hospitals throughout the area, and it is these hospital relationships that help to define the staff compensation arrangements.

AMP does not pay physicians incentives. Instead, it has developed co-management agreements with its hospital partners and incentive models are contained within those agreements. These specify goals for AMP to achieve, which are closely measured and ultimately improve patient care and monetary savings for each of the hospitals, Williamson said. “We are essentially partnering with the hospitals, with working toward a common goal.”

Of course, there is no single perfect model, and AMP is always working on refinements. “Everyone contributes in a different way, and when the water rises, the boat rises,” said David M. Albala, MD, medical director and co-director of research at AMP.

AMP was founded 10 years ago when 2 competing urology groups merged, bringing 11 urologists and 1 radiation oncologist between them. “Essentially, there were 2 large practices that were practicing against each other, so to speak, and they sat down and talked to each other and said, ‘Let’s see what we can do to try to combine forces,’” Albala said.

“The vision of AMP was to merge the urologists in the area under 1 corporate umbrella to develop AMP into a fully integrated healthcare organization in order to provide better continuity of care to patients, while offering the most advanced treatment options and skilled specialists within the system,” said Williamson, who was hired in June 2007 to help with the initial merger and build the practice.

In 2008, the group provided services at 3 hospitals, with the main center located in Syracuse, New York, with 4 offices. The main campus of AMP featured a radiation department and eventually developed a pathology laboratory. Albala, a specialist in robotic surgery, joined the group in 2010.

AMP steadily worked to achieve its larger business objective by combining with nearby urology groups who were competing with AMP. In 2009, 3 urologists who had been in practice together for over 20 years merged with AMP. Their office was about 30 minutes from the Syracuse clinic. From there, AMP started recruiting and adding more physicians, as some older physicians decided to retire. In 2010, 2 more urology groups merged with AMP, with 3 others following suit in the ensuing years.

“Over the course of mergers, there were several offices that were closed down due to the proximity of the other locations to increase efficiency, or for cost-saving measures. Also, by recruiting outside physicians, we were able to expand into other markets that were underserved,” Williamson said. Currently, AMP is the largest urology group in its market. “Patients are able to visit the satellite offices to receive the majority of their care, but at times they need to travel to have the more specialized services,” Williamson said.

“We never envisioned that we would become the only independent private practice urology group in the city of Syracuse and its surrounding counties,” said Howard J. Williams, MD, FACS, CEO of AMP.

In terms of the size of its team, AMP now has 22 physician owners, 6 nonowner physicians, and 300 employees, 275 of whom are full time. AMP does not currently have a medical oncologist but is seeking to recruit one to better accommodate patient needs.

When recruiting more doctors to their group, which is typically a difficult task, AMP strives to offer compensation plans that are competitive with other large institutions across the country. “We have recruited several doctors from outside the area who have uprooted from North Carolina or South Carolina and come to the Syracuse area,” Williamson said.

AMP offers a broad menu of diagnostics, treatments, and procedures. For diagnostic imaging, it has ultrasound and CT scan equipment, as well as an MRI fusion biopsy program for prostate cancer testing, which was started about 2.5 years ago, Albala said. However, it does not currently have nuclear medicine imaging.

There is a state-of-the-art intensity-modulated radiation therapy facility, not only for treating patients with prostate cancer, but also for patients with breast, and head and neck cancers. To raise the level of treatment for patients in need of radiotherapy, the practice has a partnership with AMP Radiation Oncology, a division of AMP, which handles the professional end of AMP’s radiology needs, including reading CT scans, live ultrasounds, and administration of radiotherapies to patients. There is an onsite radiation oncologist, and any AMP office can call that doctor and receive immediate answers to questions.

AMP also offers traditional surgeries and has a robust robotic program for prostatectomies, partial nephrectomies, cystectomies, and other procedures. It also has procedures for other urologic diseases, such as UroLift and Rez&#363;m for benign prostatic hyperplasia.

AMP’s advanced prostate cancer and bone health clinics enable patients to come in for treatment and be seen at the same time by an oncologist, Albala said. When the advanced prostate cancer clinic opened, it was led by 1 physician with a keen interest in that disease state. Over time, the physicians at AMP have made that program more comprehensive and robust. According to Albala, the advanced prostate cancer clinic has enabled care from the beginning of the diagnosis through to chemotherapy. The physicians start patients with prostate cancer on sipuleucel-T (Provenge), then progress them to oral agents, including abiraterone (Zytiga) and enzalutamide (Xtandi), in a graduated program.

AMP has also started an in-office dispensing system for drugs to better manage patient adherence, and practice administrators have considered hiring an oncologist to administer chemotherapy and other infusions in the office. The bone health clinic has succeeded in managing patients who are on hormonal therapy. The practice is branching out in other ways, Albala said.

“We are starting to develop an overactive bladder clinic for patients who have overactive bladder. They can come and be treated by experts in pelvic medicine. We’re starting to look at ways we can treat patients with bladder cancer and kidney cancer and how we can hang onto those patients a little bit longer than we used to.”

Because AMP aims to provide the most recent and effective treatments possible, it also has a clinical trial program. The research department is made up of 5 members, with research coordinators, including Albala, and a clinical trial manager. Although these trials include many investigative drug therapies, AMP also participates in trials of medical devices. Albala noted one study of a new biopsy device for probing the prostate that is sensitive to differences in radiofrequency and can recommend a biopsy based on results.

Over about 7 years, the clinical trial program at AMP has included as many as 48 studies, and today there are over 30 open trials that patients can participate in. The research team of physicians and coordinators meets regularly to make sure things are running smoothly in all trial activities. Practice administrators say that AMP is consistently a high enroller for clinical trials, and at large urology conferences, AMP is often asked by companies to participate in their research.

AMP makes a concerted effort to do community outreach. Physicians visit nearby primary care physicians to learn about local health issues and it holds forums for patients to promote better understanding of urologic conditions, such as erectile dysfunction and overactive bladder. AMP also partners with hospitals in other educational endeavors. The physicians at AMP participate in the ZERO Prostate Cancer Run every year, which raises funds and awareness for patients with prostate cancer and their families.

The outreach program has been successful in drawing more African American patients from the Syracuse area into AMP’s offices for treatment and consultations. African American men have some of the highest rates of prostate cancer and related mortality, so this program was established to educate this at-risk population and set up screening programs, Albala said. To broaden this program, AMP has reached out to community centers and churches. “We do rectal exams and PSA screenings and try to educate these men to be more aware of their condition and what prostate cancer means in the African American community,” he said.

AMP seeks to continue to grow and provide compassionate, state-of-the-art care to all members of the Syracuse community. Part of its plan to achieve this goal is to always keep up with new developments and treatments, while maintaining a robust research program. “We want to stay on the cutting edge of technology. We will spend the capital to make sure the patients can come here and have the best possible equipment available,” Williamson said. Physicians at AMP also publish and present research at national meetings to further collaborate with their colleagues outside their practice.

“This practice is unique in that, I think, it’s as good as any university practice in the country,” Albala said. “What we’ve been able to do is unique. Granted, we’re a large practice, so it’s easier to do those things, but we really have provided comprehensive care across the board.”

Associated Medical Professionals of New York, a urology and radiation oncology practice, seeks to give its physician partners an equal share of its financial success while rewarding all staff members according to their levels of responsibility and workflow intensity.

December 2017 | Oncology Live Urologists in Cancer Care®

Reflecting Back, Looking Forward in Urology Practice

A Practice Model Designed to Reward Physician Partners Equally