Matthew Shuford, MD
Jerri Wilson, CEO of Urology Clinics of North Texas (UCNT), said it was last summer that payers started making it more difficult to gain payment approvals. “We saw an increase in demand for records and more scrutinizing of notes and data,” she said. More patients were being denied for coverage for tests and procedures. The practice was feeling the effects of a payer backlash against the rising costs of care. As manufacturers charge increasingly higher prices for new therapies and even well-established agents, payers have responded with pressure on practices to justify every cost, and UCNT, like many other independent practices, is caught in the middle.
Matthew Shuford, MD, president of the Board of Directors at UCNT, agreed. “People always have trouble paying for things, and certainly insurance is the biggest determinant of that, or lack of insurance, or maybe inadequate insurance,” he said. However, Shuford noted that “even in areas where a practice would traditionally see an approval for certain cancer medications or necessary scans, the amount of prior authorization or peer-to-peer review needed has risen dramatically.”
The added difficulty in gaining approvals has placed an extra burden on the practice. Not only is it more difficult to gain payer approval, some claims are no longer being accepted at all. “It’s become quite costly to our organization to have staff to cover the increase in demand from the carriers,” Wilson explained. “For instance, for our male patients, testosterone treatment is an example of a type of service that carriers are now denying, or they’re limiting the service.”
Despite these payer challenges, UCNT has found ways to thrive and grow, both by building up its in-house offerings and by collaborating with outside providers to improve coordination of care and quality of service to patients.
Enjoying a Niche for Urologic Care
In the Dallas-Fort Worth metro area, UCNT is a large, multilocation practice that covers the gamut of urologic care. Practice administrators said they are fortunate in that in their market, they have little competition. The hospitals in their area don’t hire urologists. Consequently, UCNT has seen tremendous growth since it was founded in 1999. Along the way, it has upgraded its operations by coordinating care with outside specialists, bringing more care options in-house, and employing data analytics to track patient care and to improve efficiency and outcomes.
Although not the largest urology group in northern Texas, UCNT has a broad reach, with 16 locations that cover about half of the Dallas-Fort Worth metro area, Shuford said. The practice started with a merger of 3 smaller practices 18 years ago. The physicians sought growth and an improved payment structure. In 2005, the practice expanded again to broaden its offerings, improve performance measurement, and upgrade services. Now, in 2017, UCNT has a total staff of about 270 employees. Among its providers are a radiation oncologist, 3 pediatric urologists, and 35 adult urologists.
The doctors anticipate further staff growth this year. “Most of that growth is because this is 1 of the fastest-growing areas in the country. We’re growing out into the suburbs and areas that we presently don’t cover,” Shuford commented. To keep that rapid growth going, the physicians have created infrastructure that will enable them to add types of patient care that they don’t presently offer.
The practice’s immediate goal has been to prepare for any value-based changes required by commercial payers or under the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015, which is nudging all practices towards an incentivized payment structure that rewards and penalizes based on quality-improvement measures. “That’s been our focus here in the last 6 to 8 months—how we can improve the care we deliver, in terms of reduced costs and better value, both for the patient and the payers,” Shuford said.
The physicians are also trying to improve the quality of care and to grow by coordinating care with subspecialists in their geographic area. UCNT is working to combine its relationships with nephrology and cardiology subspecialties, among others, into an accountable care organization (ACO). They’ve been collaborating with these groups for about a year.
The attempt to create an ACO represents the practice’s largest partnering effort so far. What the doctors are trying to create through these collaborations is a “specialist ACO.” Shuford said that while most ACOs are centered around primary care, UCNT wants to create an ACO centered around urology, for a greater benefit to their patients.