An inside look at how the Michigan Institute of Urology is navigating the shifting healthcare and civic landscape.
Michigan Institute of Urology’s St. Clair Shores building
The events of 2013 would seem to ensure a bumpy ride ahead for Michigan Institute of Urology (MIU). In July, the city of Detroit filed the largest municipal bankruptcy in US history. MIU is the largest group practice in the southeastern part of the state, with more than two dozen offices serving patients in and around the stalled Motor City.
A few months later, the Affordable Care Act (ACA) kicked into high gear and, along with the rest of the country, MIU watched the chaos that ensued during the federal government shutdown, not to mention the ongoing struggle to get patients on course with health insurance coverage.
Alphonse M. Santino, MD
But for practice founder and CEO, Alphonse M. Santino, MD, unexpected twists and turns in the road seem inevitable. He has no doubt that MIU can stay on track as the area’s most established urology subspecialty care provider.
“At this point, we haven’t seen any fallout from those events,” Santino said. “Will it be coming? Sure. Change is definitely coming down the pike. But that’s a benefit of having a large-group practice. We are in a position where we can address these kinds of shifts without too much disruption. We have the resources available and are prepared for changes, both inside and outside medicine.”
Santino, along with practice partner and urologic oncologist Kenneth M. Kernen, MD, shared with Urologists in Cancer Care how MIU is successfully navigating a shifting healthcare and civic landscape.Santino opened his single-physician practice in 1967 in the Detroit area. A year later, he was drafted by the US Army and served as a major in the medical corps in Long Bing, Vietnam. Santino returned to his practice in 1970 and remained its sole urologist for a number of years. Between 1975 and 1980, two more practice members came on board. These physicians, James Boutrous, MD, and Robert Di Loreto, MD, are still with MIU.
Santino saw the oncoming changes in healthcare and prepared for them sooner rather than later.
“We stayed a three-man practice for some time. In 1991, the HMOs were starting, and my feeling was that the practice of medicine was going to change radically. I felt that a group of three urologists was not going to fit into the ‘new healthcare’ picture. A small practice wasn’t going to be able to respond to the demands of practicing medicine on a larger scale. So I decided to expand the group.”
Santino focused on recruiting fellowship-trained urologists from premier institutions such as Memorial-Sloan Kettering Cancer Center in New York City and the Cleveland Clinic.
“The goal was to bring on the best and brightest, not only for their skills, but because they are physicians who will respond to change the best,” Santino explained. “Each year, we added a new doctor. Along the way, we merged with several smaller, existing urology groups.” The most recent merger took place in 2011.
Jason Hafron, MD, reviews films.
MIU now has 51 physician members, 24 locations, and professional relationships with every major hospital system in southeastern Michigan. The practice has more than 400 employees, including nurses, nurse practitioners, and medical assistants.
In the last few years, the practice has made major inroads in terms of technological expansions, including an electronic medical records (EMR) system that’s been online since 2011. Santino said MIU is pleased with what the EMR has done for the practice, namely bettering communication between the patients and their healthcare providers, and improving the practice’s overall efficiency, for example by reducing office wait times.
MIU also has a rigorous internal auditing system in place to ensure that patients see the right physician for their disease conditions.
“The auditing department will not allow one of our physicians to take a case that he or she is not trained for,” Santino said. “We want to make sure that our patients see the appropriate, subspecialty-trained expert in our practice for their conditions. Now, our partners are allowed to assist each other with a case if they wish to, but a general urologist who has a patient that requires a radical prostatectomy would not be allowed to do that procedure.”
Finally, the practice is in the process of implementing the new ICD-10 code sets.
Altogether, these online upgrades mean that MIU answered “yes” to a perpetual question raised about the ACA: Can practices handle a potentially higher caseload of patients while striving to keep healthcare costs down?
“The size of our practice allows us to offer a range of care that smaller practices can’t,” Santino said, referring to MIU’s onsite diagnostic, lab, and surgical services. “We can also offer these services at a lower cost than a hospital, which works out well for the practice and the patients.”A visit to the MIU website reveals a comprehensive “Patient Dashboard.” Here, patients can request appointments, pay bills, take surveys for feedback on their MIU experiences, and request prescription refills. The “Patient Resources” area offers detailed information on urologic diseases and treatment options, as well as the practice’s clinical trials arm.
Rather than being wary of patients with a little knowledge, MIU’s aim is to empower its patients before they walk into the doctor’s office. In addition to its website, MIU offers waiting rooms that feature pre-recorded, televised programs in which practice members discuss their areas of specialty.
Kenneth M. Kernen, MD
“Education is akin to comfort for patients,” Kernen pointed out. “My goal is to be an educator, not a dictator. I want to build a relationship with my patients. If they come into my office with some basic understanding of what’s ahead for them in terms of diagnosis, treatment options, etc, that makes my job easier and gives them a level of comfort.”
That level of reassurance often makes patients more open to less aggressive—and potentially more cost-effective—disease-management strategies, such as active surveillance in clinically localized prostate cancer.
For instance, when Kernen consults with these particular men, rather than having a discussion right away about taxing and expensive treatment options, he can suggest a test like Prolaris, which measures the genetic expression of tumor proliferation in an effort to predict prostate cancer disease outcomes.
“Instead of coming to see me and insisting on treatment, patients are excited to hear about a test like this, especially when they find out it could spare them the time, expense, and discomfort of extensive treatment,” he said. “With good testing and education, we can make active surveillance a more common and acceptable option to patients. Ultimately, we’re doing what’s best for them and their healthcare dollars.”
Giving patients online access to its menu of urology care services is also a boon because it allows MIU to find a balance between being a productive, multi-million-dollar large-group practice and offering a personal touch, Kernen added.
“We’re like a university in a private practice setting,” he said. “We try to make it as easy as possible for our patients to work with us before they even come in for an appointment. We offer the high level of expert subspecialization that you expect from an academic hospital, and this allows our patients to get the best care. But we still have the appeal of a small-town practice.”
Part of that small-town appeal comes from having the opportunity to get to know patients as individuals. In prostate cancer in particular, the variety of treatment options means Kernen will be a part of his patients’ lives for many years.
“That’s one of the attractions of the field,” he said. “We like the idea of having long-term relationships with patients. Part of what we do as urologic cancer specialists is offer hope. I can tell my patients ‘We are going to do everything we can to make you well. Now, we may never cure your cancer, but we can treat it so that you can live with it and still see those huge milestone events in your life and in your family’s lives.’”
This ongoing connection also means keeping up with patients’ overall wellbeing. When it comes to issues such as weight management, smoking cessation, or healthy lifestyles in general, Kernen said he’s had patients who come to see him before they do their primary care physician.
“We do talk to them about adopting and maintaining a healthy lifestyle,” he said. “We then direct them into programs that will help them achieve those goals, whether it’s through the primary care doctor or through multidisciplinary care at a cancer center.”
While growth beyond southeastern Michigan isn’t on MIU’s road map for the near future, according to Santino, there is one area where Kernen said he’d like to see the practice—and society in general— pull ahead: building prostate cancer awareness.
“In the US, almost 30,000 men are going to die this year of prostate cancer. So no matter how much people want to argue about the details of prostate cancer— should we or shouldn’t we screen with prostate-specific antigen [PSA] testing?— we’re still missing the bigger picture, which is the number of men who will die from the disease,” Kernen said.
He would like to see prostate cancer become an acceptable topic of discussion among men the way breast cancer has for women.
“Women have done a much better job of raising awareness about breast cancer,” Kernen said. “If one woman is diagnosed with breast cancer, she goes and tells her friends and family. If a man is diagnosed with prostate cancer, he’d prefer not to tell anyone. One of the primary challenges that we have to face as urologists and as a society is encouraging men to be OK with having prostate cancer and to be willing to talk about it.”