Jeffrey Spier, MD
A group practice that adopts an eat-what-you-kill mentality in which compensation is grounded in activity-based cost-accounting practices, can benefit even more by expanding its collaborative and cooperative efforts. In eat what you kill, physicians are paid based on how much revenue they produce and expenses are paid individually.
An advantage of this mentality is that it combats the issue of medical group inertia, which is brought on by unproductive and uncompensated activities related to financial squabbling. The bickering and sniping can drag group morale down, along with income levels. Physicians, who are generally highly independent people, can get caught in the doctrines and quirks of group dynamics that run counter to their natures.
This philosophy won’t work for groups that lack a shared sense of obligation and culture.
As a group, Rio Grande Urology shares a sense of obligation and culture. Its leaders have embraced an integrative model approach and sees the advantages of it. It was formed by 4 urology practices merging to build a main campus that houses the cancer center and radiation therapy center. The group includes 16 physicians, 4 mid-level practitioners, and over 130 employees in El Paso, Texas, and Las Cruces, New Mexico.
The Integrative Practice
“The integrative practice makes everything centralized,” said Jeffrey Spier, MD, managing partner. “It’s a model that we’re building upon. The future of medicine reduces duplication of services, so we’re seeing a lot of cuts in test ordering. Patients are noticing an increase in the seamless care that we provide.”
Discussions about patient care can encompass radiation oncology, medical oncology, urology, and now, in a unique situation, gynecologic oncology. Spier said the relationship between urologic oncology and gynecologic oncology is significant. “They are pelvic surgeons and so are we, so we collaborate about surgical issues.”
There were a number of reasons that partnering with a gynecologic oncologist made sense, said Spier. He points toward the radiation model, which helps to draw the entire group together. “First, many of gynecology oncologist’s patients receive radiation therapy, and his practice is in the same complex as our radiation center. This enhances our collaborative efforts. Second is the convenience factor for his patients. They are able to have access to consultants, including medical oncology and our radiation oncologist, as well as imaging options that include computed tomography and ultrasound located on the same campus. And third, the gynecologic oncologist can continue to teach in the academic setting, but maintain a private practice.”
The collaboration can also open up future opportunities. “We have begun using high-dose rate (HDR) radiotherapy for pelvic tumors that involve different types of gynecological cancers. The capacity to collaborate revolves around that cancer front,” said Spier.
The integrative mindset has taken hold across the country, said Spier, whose partners have bought into this group structure. Going back to a solo practice or small practice would not be an option, although Spier admits there is greater autonomy associated with a small practice. The collaborative model does require giving up a certain amount of autonomy.
But in today’s healthcare reform environment, a collaborative mindset can improve patient outcomes. He points out, for example, the opportunity to optimize the use of referrals within the practice. “Should I continue to perform a robotic prostatectomy, which I may schedule once monthly, or should I refer to a colleague who has done the procedure hundreds of times? What’s important here is the patient outcome. Leave the ego at the door,” he said.
There are further opportunities for the initial referring urologist, said Spier. “This allows me to open my practice up to more general urology, for example.” In the practice, subspecialization is readily embraced. No one urologist can be the best in all aspects of delivering care, and the structure of the group permits and encourages referrals.
“Originally, our group had a top-down structure, with a CEO at the top,” he said. “It did not work out as well as we hoped because physician involvement in administering and running the practice was lacking. We learned that the practice functions better when physicians have ownership. In the past 2 years, we incorporated a managing partner and medical director. We’ve seen practices that rely solely on administrators, with no physician involvement, slowly go away, and we didn’t want that to happen here.”
Changes in Prostate Cancer Management
One of the characteristics of a large practice is the breadth in treatment it brings to men with low- and high-grade prostate cancer.