SouthWest Urology Uses Quality-Focused Integrated Care Mode

Michael Barkoukis, MD

Michael Barkoukis, MD, and Tim Sidor, MD, started SouthWest Urology of Cleveland, OH, in 1982 from scratch with $100,000 in borrowed capital, a box of pens, and a copy machine. Both men grew up on the west side of Cleveland, and both ended up at Case Western Reserve University in the same medical school class. Both aspiring urologists were accepted into a residency program at the University Hospitals in Cleveland, and as their training progressed, they decided to begin a urology practice together. “I had looked at several other jobs in the Cleveland area, but I felt that there was a niche on the southwest side of Cleveland,” Barkoukis said.

From those humble beginnings 35 years ago, the successful practice has grown to include a main office in Middleburg Heights, 5 additional locations, a team of 9 urologists, and a support staff of 60 full- and part-time employees, including 20 surgery center staffers.

Integrated Model of Care

The greater Cleveland area in Cuyahoga County is dominated by hospital groups that offer oncology treatment, among them the Cleveland Clinic and University Hospitals, but SouthWest has become the largest independent urology practice. “We’ve tried to differentiate ourselves from the larger academic centers, and we would like to continue to do that,” said Lawrence A. Gervasi, MD, CPI, medical director of clinical research and director of SouthWest’s advanced prostate cancer clinic.SouthWest is proud of its level of integrated service. The practice has urologists who specialize in roboticassisted surgery, erectile dysfunction, the diagnosis and treatment of advanced prostate cancer, and women’s urologic health. Their diagnostics department has imaging capabilities that include computed tomography scans and state-ofthe-art magnetic resonance imaging (MRI) fusion biopsies. SouthWest also has an in-office drug dispensary. The physicians follow a model that encourages physicians to work as team players, rather than trying to do everything themselves, according to Claudio Zanin, MBA, CEO of SouthWest Urology.

“I’ve seen a lot of different compensation models that focus more on productivity—and the more you work, the more you make. Our model lends itself to quality, where a doctor sees a patient, explains the situation, and refers the patient to someone who is really good at doing the procedure,” Zanin said. Because the practice offers all aspects of urological care, a collaborative culture fostered by the integrated model is crucial to taking care of patients, he added.

The comprehensive, integrated care at SouthWest helps the practice to compete with the diversity of offerings at hospital systems as Cleveland Clinic, said Barkoukis, who is president of SouthWest and clinical professor of Urology at Case Western Reserve University. “A lot of our patients like the idea that they can pull into a local neighborhood parking lot, come into the building and see their doctor, have their x-ray performed in the same building, and have their surgery.”

However, when it comes to systemic chemotherapy, the practice does not have a medical oncologist to manage patients on this treatment, so patients must be referred elsewhere. To resolve this, the practice is considering hiring a medical oncologist to bring that area of care to their practice. The only oncology service they do not have avaialble is pediatric oncology.

Partnerships Providing Quality Care

For the last 10 years, SouthWest’s main office has been in Middleburg Heights, which has its outpatient ambulatory surgery center and imaging centers on the first floor, offices on the second floor, and the research center on the third floor. They also have 5 satellite offices, 1 in Medina, OH, 1 in Brook Park, OH, 1 at St. Vincent Charity Medical Center in Cleveland, and another at Marymount Hospital in Garfield Heights, OH.The company is able to obtain experimental treatments for patients through a collaboration with a company that manages clinical trials. “We have a unique situation where we work with a company that’s called Clinical Research Solutions. They supply the clinical research coordinators, and I do the physician’s part, recruiting patients for trials,” said Gervasi. A few years ago, when SouthWest first decided to do clinical trials, they realized that outside expertise would be critical to managing the program effectively.

The challenges for an independent practice running studies can pile up quickly, practice members said. Revenue for studies is not booked consistently, and funding may have to come from the practice itself to cover interim costs of staffing and resources. If a practice should make a mistake in their administration of a trial, they may never get paid or be able to cover all the costs involved in running a study.

“You really need to know what you need to do in terms of all the paperwork, and there are a lot of things that need to be done to run a clinical trial, and if you don’t do them right, you’re not going to get more studies,” Zanin said. The way that the clinical trials program is set up now, there is very little overhead cost, the physicians are in touch with Clinical Research Solutions every day, and SouthWest is satisfied with the way the program is running.

SouthWest is satisfied with the way the program is running. SouthWest has what Gervasi described as a very active clinical trials program. He said the practice is currently recruiting patients for 12 to 14 clinical trials. A number of them are for prostate cancer, but there are also trials in benign prostatic hyperplasia and overactive bladder. “What’s helpful is that this also extends a lot of opportunities to patients who may not be candidates for FDA-approved drugs for prostate cancer because their disease is not advanced enough, so these are people we’ll consider for a trial so they can be treated with some kind of medication rather than waiting until they have metastatic disease,” Gervasi said.

Prostate Cancer Clinic

The trials with which they are currently involved are intended to show how well oral drugs are going to work for patients with early stage prostate cancer. “We just got approved for a trial using one of the PARP inhibitors for prostate cancer, so I think that’s another exciting new area for a drug class that’s been approved for ovarian cancer, and now it’s being looked at in the area of prostate cancer,” Gervasi said.SouthWest’s prostate cancer clinic began as a clinic for patients with prostate cancer who received treatments that affected their bone health. Doctors in the clinic would make sure that patients were taking their medications and getting their vitamins, scans, and imaging. Over time, the program evolved into an advanced prostate cancer clinic.

As more medications and treatments become available, SouthWest hopes to add these to its drug armamentarium in order to retain the patients under its care and attract new ones. “What happens is when people get to the point where they have advanced prostate cancer, they’ve already been at our practice for possibly many years, so they’re very comfortable with us; they’re very satisfied with the care and they don’t like to leave the practice, so that’s why it’s nice to be able to offer these treatments right here at our practice where they feel comfortable,” Gervasi adds.

The broader range of therapies has made the treatment of prostate cancer more optimistic, he added. “There are all these new therapies that were not available about 6 years ago; there’s also drugs for bone health that we give, and all these are available to the patients, which really gives them more hope than they had just a few years ago. All of these improve overall survival, so patients are happy to hear this, and it’s a very good atmosphere for patients with advanced prostate cancer,” Gervasi said.

SouthWest recently started offering MRI fusion biopsies for the patients, as other large practices are doing. MRI of the prostate and MRI fusion biopsies are newer procedures that help determine whether a patient would be placed on active surveillance or not. These tests combined with genomic testing are helpful to discern how aggressive a patient’s prostate cancer is and to determine how aggressive the therapy should be.

Just a few years ago, there was a lot of debate within the practice a few years ago about whether they should utilize this new technology. According to Zanin, the issue was that they would not be compensated for MRI fusion biopsies, and the cost was over $100,000 for the equipment. “You have to look at things from a business standpoint, because no money, no mission,” Zanin said. Although the practice could not bill payers for MRI fusion biopsies, patients were asking about the procedure, and finally everyone in the practice decided they needed to make these tests available. “We found a way around things to do it at the hospital, which is good, but the next step is to bring it under our domain,” Zanin said.

Struggles for Growth, Future Goals

The need for high-quality prostate clinics has been on the rise lately, and this gives the partners at SouthWest the sense that they are well positioned for this trend. “What’s been documented across the country, amid the controversy about PSA screening, is that in general fewer of the primary care physicians are screening, so we have seen the number of biopsies and the number of people being diagnosed with prostate cancer decreasing over the last few years, and that also corresponds to an increase in incidence of higher-grade and higher-stage prostate cancer,” Gervasi said.The goal for SouthWest is to continue to grow their practice, but they must compete with Cleveland Clinic and University Hospitals for employee candidates. It’s difficult to recruit urologists because hospitals are able to offer higher salaries, and because more urologists are retiring than are graduating. “It just seems that the old-school urologists and the new-school urologists may have different types of mindsets. The new urologists coming out of school may be looking to go toward the [hospital] system to get more security and not be on call so much,” Zanin says.

SouthWest’s partners have discussed growing by merging with other private practices so they can continue to provide integrated, high-quality, efficient care to their patients. Zanin believes that they need to recruit more urologists or partner with other independent practices. Until now, urologists have come to the practice 1 at a time, instead of through mergers. “Part of what makes this group successful is that we’ve made a culture that allows us to continue to grow, and now we need to grow more,” Zanin said.

Despite the recruitment challenges, SouthWest has a lot to offer a urologist, including autonomy and the possibility to work up to a partner position. “Because of the bricks and mortar, the physicians, the salaries they get paid, and the size of an institution, the cost of delivering care in [hospital] systems is much higher than the cost of delivering care in an independent practice like ours,” Barkoukis said. “If you can get the same quality care, and you can get it done efficiently and easily by a group like ours at a lower price, and as the patient becomes a consumer with higher deductibles and health savings accounts, they’re going to be looking for treatment that can be done cheaper as long as it’s comparable, especially if it can be done in their own backyard.”