Blazing the Oregon Trail: Oregon Urology Institute Nurtures Its Position as a Urology Care Leader

Urologists in Cancer Care, February 2013, Volume 2, Issue 1

An interview with Bryan Mehlhaff, MD, and retired physician Robert Litin, MD, about how Oregon Urology Institute is adapting its well-established practice to an ever-shifting healthcare landscape.

Oregon Urology Institute

The cornerstone of the Oregon Urology Institute (OUI) business model was kidney stones: In 1997, two separate practices, Oregon Urology Specialists and Urology Healthcare, joined forces to start a lithotripsy service.

“That joint venture helped build a lot of trust between our two practices,” explained Bryan Mehlhaff, MD, medical director of what is now known as OUI. “Then we started talking about building a clinic that we would own together. For a short period of time, we functioned as two parallel groups but practicing in the same space. Little by little, we started merging our billing, scheduling, and clinical functions… then formally merged into OUI.”

Headquartered in Springfield, Oregon, the practice boasts 15 physicians and five physician assistants. Its services include an imaging center, a surgery center, pathology lab, a physical therapy program, and a radiation center that is dedicated solely to prostate cancer treatment.

Although OUI is the dominant provider of urology care in the area, this large urology practice isn’t immune to the economic challenges in light of the recent changes in healthcare, such as the implementation of the Affordable Care Act (ACA), wrangling over the high cost of care, and meeting the demands of a growing patient population.

Robert Litin, MD

The Prostate Cancer Challenge

Urologists in Cancer Care spoke with Mehlhaff and retired physician Robert Litin, MD, about how OUI is adapting its well-established practice to an ever-shifting healthcare landscape.The screening and treatment of prostate cancer has been the subject of intense debate and controversy in recent months. Many feel the field faltered when the US Preventive Services Task Force (USPSTF) came out with its recommendation in 2011 that healthy men should no longer have PSA measurements as a screening test for prostate cancer. However, tremendous strides have been made in the treatment of advanced prostate cancer, including the immunotherapy sipuleucel- T (Provenge) and the therapeutic agent abiraterone acetate (Zytiga). Despite the controversy in this area, Mehlhaff has strived to make a difference in the treatment of prostate cancer at OUI.

“I’ve been the champion of treating advanced prostate cancer in our group. It took a while to educate my partners on the new treatments and convince them that those patients don’t have to go straight to the oncologist. So I’ve made it a mission to help my group look at the treatment opportunities that we have here,” he said.

But these treatments come with significant price tags that may seem to put urology at odds with the current ethos of cost-cutting in healthcare. However, Mehlhaff pointed out that, unlike other cancers, therapeutic options in prostate cancer have come about at a slower pace.

Bryan A. Mehlhaff, MD

“There hasn’t been as much development in prostate cancer as there has been in colon cancer or breast cancer, for example,” he said. “Both those disease states currently have a lot of very expensive, but effective, therapies associated with them. In some ways, we are just catching up in urology in terms of what we can offer prostate cancer patients. So at this point, these treatments seem very expensive, but if you compare it to the cost and efficacy of common treatments for other cancers, the costs are not out of the ballpark.”

Not that OUI advocates a “treat all comers” approach. “Our job here is to do what is best for our patients, and that doesn’t mean that every patient should get the most expensive and aggressive therapy,” Mehlhaff said. “I recently had a very elderly patient who expressed interest in Provenge. With his array of other medical problems, I didn’t feel he was an appropriate candidate for that treatment. Instead, we looked at oral therapies for him. I think using our clinical knowledge is the best way to implement cost control.”

But there is a concern that the USPSTF recommendations against routine PSA testing will send prostate cancer back to a time when men arrived at the urologist’s office with advanced-stage disease. Litin, who retired from OUI in 2012 after 59 years of practice, recalled a time when “watchful waiting” meant something very different in prostate cancer patients.

Community and Clinical Trials

“There was a time where we’d perform the prostatectomy and then go to bed that night hoping that the patient made it to morning and didn’t bleed out,” Litin said. “It was that kind of a major operation. In addition, at that time, we had no idea of knowing whether the disease had spread. So that’s where PSA made some difference, although it gave us limited information. We didn’t have the PET scans and other tests back then."With the passage of the ACA, it’s estimated that 30 million more Americans will join the ranks of those with some type of health insurance coverage by 2015.

For OUI, that will mean adding to their already full plate. “We are essentially the only provider of urologic services in our county,” Mehlhaff said. “The only procedure that we don’t do here is kidney transplants, but all the other urologic cases come to us. So we know that we are already meeting the needs of our patients, and we believe that we’ll continue to do that with this potential pool of new patients.”

One way to manage these patients is, when appropriate, enrolling them in a clinical trials program. Some of the trials that the practice is now involved in are:

  • A phase II, randomized efficacy study of enzalutamide (Xtandi) versus bicalutamide (Casodex) in men with prostate cancer who have failed primary androgen-deprivation therapy
  • A phase II, randomized evaluation of DN24-02 as adjuvant therapy in subjects with high-risk HER2-positive urothelial carcinoma

OUI also maintains its leadership position in urologic care through its Oregon Urology Foundation. This nonprofit arm of the practice bestows grants in the range of $10,000 to $25,000 to other nonprofit advocacy organizations, such as Volunteers in Medicine, a clinic that provides free medical care to uninsured working adults in Deschutes County, and Friends of Florence, a group that arranges transport of cancer patients from small towns to the Springfield/Eugene area for treatment.

The foundation also sponsors free prostate cancer screening events, which are funded through a Father’s Day Prost8K run/5K walk. In addition, the group hosts a professional continuing medical education program, the Oregon Urology Symposium, for primary care providers in the region.

In 2012, the foundation, in conjunction with Lane Community College in Eugene, Oregon, created the Olof E. Sohlberg, MD, Memorial Scholarship. The $50,000 endowment will fund annual scholarships for students in the college’s nursing program.

Mehlhaff credits Sohlberg, a senior partner in OUI who passed away in 2011, with pushing the practice outside of the exam room and into the community.

“He was a great champion of doctors getting out and being active members of the community, encouraging them to see that it wasn’t enough to just practice,” Mehlhaff said. “We have a successful practice, and we want to give back to the community. It’s not just about being a good physician; it’s about making a difference in the bigger picture.”