Virginia Urology, a practice with specialists in surgery, radiation, and oncology, has grown steadily over 75 years by remaining patient focused. Centered in Richmond with multiple locations along the Interstate 95 corridor, Virginia Urology has always prioritized quality care—not just in the office but outside too&mdash;for example, when providing follow-up care. To the physicians, this makes financial as well as ethical sense.

The group encompasses 7 clinics, a dedicated urology hospital, and 2 ambulatory care centers. “We want to grow in a sense that covers all aspects of medical care and make the fragmented healthcare system more cohesive,” Charlie Jung, MD, a urologist at Virginia Urology, said. He added that the group didn’t make it a goal to become a large practice; it just happened that the demand for its services was strong. “We never started acquiring groups for the sake of getting bigger. It was about taking care of patients in the Richmond area.”

In September, Virginia Urology opened the doors of its newest Richmond facility—a 90,000-square-foot treatment center that includes an ambulatory surgery center with 9 operating rooms, an imaging center with computed tomography and MRI, an infusion center, and an expanded pathology department with a molecular diagnostics laboratory. The new center was created from a preexisting structure that Virginia Urology renovated and modernized.

The new facility enables the group to better cover the continuum of cancer care, from initially seeing a patient in the office to following up with diagnosis, surgery, or other treatments to managing care when the patient goes home. Jung says this is how they can best ensure quality care and overcome any challenges presented by poor coordination in the broader healthcare system.

Sometimes ahead of payers’ readiness to cover new treatments, Virginia Urology has found ways to provide the cutting-edge therapy that patients want. Over the past 4 years, the practice has been performing fusion-guided prostate biopsies. A challenge the group ran into when adopting the new technology was figuring out how to efficiently perform the procedure despite the “economic pressures” of the current health system, Jung said. When Virginia Urology first started performing fusion biopsies, payers were not covering the extra time and complicated features involved. Because of this, the practice charged patients a fee for the additional labor, time, and overhead associated with fusion biopsy. This caused problems within the group because the physicians felt that fusion biopsies were important clinically, but on the financial side, the payments didn’t cover all related costs.

“The difference between doing a fusion biopsy and a regular biopsy is that the payments are the same, but one takes a lot longer than the other,” Jung explained. “We made an effort to get payments for fusion biopsies, and we created a payment model for patients to have access to fusion biopsies [in cases of] payers that were not covering them.” Over time, as the procedure picked up popularity among clinicians, some of the larger providers began authorizing payment.

The use of fusion biopsy was so successful at Virginia Urology that the group has gone a step further and obtained certification to perform prostate magnetic resonance imaging (MRI) scans and are purchasing a 3TMRI machine. The practice has also recently hired Afshan A. Ornan, MD, a urologic radiologist who specializes in prostate MRI, to work jointly with Matthew J. Bassignani, MD, Virginia Urology’s head of radiology. Together they will be responsible for reading all the prostate MRI scans. “It’s important to have a radiologist involved because they are crucial in the planning of biopsies. They’re very helpful in marking the lesions and looking for any lesions that could have been missed,” Jung said.

The practice has found ways to coordinate the efforts of physicians so that precious time is saved and attention can be focused on the needs of patients. When reviewing a patient’s disease and treatment options, the physicians at Virginia Urology hold a teleconference if necessary to bring specialists together and then relay their guidance to the patient. This reduces the time a patient may spend waiting to see a variety of specialists, waiting for them to discuss the case, and then waiting for the results. The resulting information is shared with the primary care physician, who then has a thorough discussion with the patient about the cancer diagnosis and treatment options.

One aspect of inpatient care that has challenged Virginia Urology is the lack of control over outcomes when a patient leaves the group’s offices. “There are a lot of things that can go wrong because the people at the hospital are not necessarily under your control,” Jung said. Partnerships with inpatient facilities have enabled Virginia Urology to become involved in the preoperative work-up. When a patient progresses to surgery, everything is finely tuned, he said.

Virginia Urology has a protocol that standardizes postsurgical care: Patients receive consistent guidance on diet and home-based recovery. The practice also has a hospital program for addressing complications of care. All scheduled prostatectomy patients and their caregivers attend a class led by a Virginia Urology nurse to better understand the procedures they will undergo. This helps to manage expectations and ensure better outcomes.

Eyeing the potential to improve receipts, the group is collecting data on hospital admissions, discharges, and surgeries related to complications and protocol adherence. “We think by collecting that data, we can make a presentation to insurance companies for better payment models and for better referrals to our system,” Jung said.

Physicians at Virginia Urology share profits equally, which is rare for groups as large as they are—over 40 physicians across the Greater Richmond area. “Some may see this as a weakness because doctors aren’t compensated for [exceptional] individual work, but I find that it’s actually best for our group, especially as we move forward, because we are able to do large projects and get into new projects without conflicts of interest. You can get the whole team on board, and the team has the same goals as the practice,” Jung explained.

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Virginia Urology, a practice with specialists in surgery, radiation, and oncology, has grown steadily over 75 years by remaining patient focused. Centered in Richmond, Virginia Urology has always prioritized quality care. 

Patient-Centered Focus Drives Growth at Virginia Urology

Over the past decade, we have witnessed an explosion of molecular testing in the urology world that will help us better diagnose and manage prostate cancer across the spectrum of the disease. All of us recognize that we have fallen behind our colleagues who treat other tumor types and for whom routine lab and tissue testing is the requirement or norm for optimal therapeutic choices. However, we are making progress.

We know that prostate cancer is an endocrine disease and the androgen receptor (AR) plays a major role in disease progression, even when serum testosterone is at castration levels of the hormone. Androgen deprivation therapy (ADT) continues to be the foundation of treatment on which all other oncolytics are layered as the patient begins to progress. However, treatment pressure selection and tumor heterogeneity will result in cellular mutagenesis that makes ultimately eradicating the disease a daunting task. In patients with metastatic castration resistant prostate cancer, a number of these mutations, which will inevitably confer resistance to therapy, have been discovered. For example, prostate cancer cells that have been long exposed to ADT and are now starved of their fuel for survival can produce their own ligands to survive. This is comparable to a car that could produce its own gasoline (or electricity)—very nice if you are the automobile owner&mdash;but the reality is not so desirable for the patient with cancer. AR, the very target of ADT, can undergo genetic alterations that will result in downstream changes leading to resistance and cell survival.

Fortunately, we are in the early stages of developing biomolecular markers that will help the clinician to choose better therapies to try to stay ahead of these mutations. The ability to measure circulating tumor cells has led to the development and marketing of commercial assays to detect these aberrations—AR splice variants&mdash;that may be predictive of what agent should be used next in the treatment paradigm. In addition, patients who harbor homozygous mutations of inherited DNA repair genes, most notably 

, may in fact respond to PARP inhibition therapy. Also, DNA sequencing to test for these gene mutations can now be clinically implemented in the appropriate patient.

Thus, just as it is difficult to keep track of all the FDA-approved therapies, their mechanisms of action, adverse event profiles, and current approval status, we are additionally challenged to stay up-to-date with the molecular tests that may ultimately be required to determine when and where to use these drugs in the appropriate sequence for each patient. The vernacular commonly used in the press is the “era of personalized medicine.” I will argue that the art of medicine has always been personalized. We as providers do not adhere to a single agent, from an antibiotic to an antihypertensive to an oncolytic, for all patients. All of us consider the patient’s medical history and comorbidities and a host of other factors to best determine which agent to prescribe in hopes of achieving the best outcome. Now, given the complexity in understanding these malignancies and their ability to undergo evolutionary mutations to survive, we must clearly understand how to accurately test and target these dynamics to stay ahead of the changing tumor environment. Personalized yet ever more precise at the tumor level—precision medicine. This is how all of us will need to practice moving forward to continue making strides in advancing cancer care.

Raoul S. Concepcion, MD, FACS, discusses the explosion of molecular testing in the urology world.

October 2018 | Oncology Live Urologists in Cancer Care®

Patient-Centered Focus Drives Growth at Virginia Urology

Personalized Medicine in Prostate Cancer: Now More Precise