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 Urology Clinics of North Texas, like many other independent practices, is caught in the middle.
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.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.
The practice has a research department that always has clinical trials running. According to Shuford, it currently has trials for bladder cancer, overactive bladder, and both early-stage and advanced prostate cancer. UCNT has started using data analytics programs to search its medical records to find patients who meet certain criteria for treatment. The practice also uses data analytics to find patients whose treatment or adherence may have lapsed, such as those with missed appointments, which allows providers to ensure that patients are complying with their treatment. This improves care quality and helps the practice keep track of many different cases.
The practice also has an online patient portal, available through its website, for patients to stay in contact with their physicians, and vice versa. Patients can also use the portal to receive their lab results, request appointments, access their own health records, and pay their bills.Shuford and others at UCNT have noticed a trend of fewer referrals for elevated prostate-specific antigen (PSA) levels and, consequently, fewer biopsies and diagnoses for prostate cancer. They attributed this to recommendations against PSA screening from the US Preventive Services Task Force in 2008. Shuford predicted that eventually there will be a reckoning, when patients whose cancer could have been flagged by early screening show up later with advanced disease. “I think we’re going to see an increase in the rise of advanced-stage diagnoses of prostate cancer. Nationally, we’ve started to see those trends,” he noted. “I think we will see over the next 5 years that people at the time of diagnosis will be more advanced then they have been [in the past].” In May, the USPSTF changed their guideline statement to open PSA testing to men aged 55 to 69 (full story on page 9).
UCNT prides itself on offering comprehensive services, Shuford said, explaining, “It’s a pretty broad spectrum from initial diagnosis and local cancer care to the more advanced care.” Patients may be referred, depending upon their urologist’s initial thoughts, to someone who focuses more on surgery. The practice has a radiation oncologist and offers such treatments as cryotherapy and high-intensity focused ultrasound, Shuford said. The practice also offers medication management for androgen deprivation therapy, including enzalutamide (Xtandi) and abiraterone acetate (Zytiga).
Most recently, the practice has added MRI fusion biopsies as part of its cancer diagnosis technology. It also has a program for patients with advanced prostate cancer. These patients are referred to other physicians within the practice if their own doctor does not feel equipped to treat their disease. This way, UCNT can continue to provide the appropriate standard of care for all patients without having to send them outside the practice.
Shuford has noticed that at his practice, these days, more patients with prostate cancer seem to prefer active surveillance (if they are appropriate candidates) over interventional treatments. In the advanced setting, Shuford noted patients don’t tend to have a single treatment preference, so the team guides them through the best options.
UCNT does not currently have a medical oncologist on its team, so when a patient requires chemotherapy, that case is referred out. Eventually the practice may decide to hire such a specialist, Shuford said. Because the practice covers a wide geographic area, it refers patients to oncologists based on where the patients live. One of the referral practices is a large oncology group that employs many of the state’s medical oncologists and has also recently started employing urologists.
For patients with renal and bladder cancers, Shuford noted, “There really haven’t been any significant changes [in renal and bladder cancer treatment]. I think surgically, you’re seeing more use of minimally invasive or laparoscopic or robotic surgical techniques, as opposed to the traditional open techniques. We’re also seeing more emphasis on partial nephrectomies as opposed to radical nephrectomies, when appropriate.”When Shuford and his colleagues look back, they realize that the best advice they can pass on to other independent urology practices is to have a defined vision of the practice from the beginning. “If you’re going to set off early, have a better vision of standardization and uniformity right from the beginning. Understand that if you’re going to be 1 group, you need to be 1 group, with a single pay model and a single expense structure. Also, you should start thinking about how referrals and coordination between the divisions are going to look,” Shuford said.
There will be growing pains as any practice grows, but Shuford noted that it’s better to go through those challenges early, rather than when the practice has doubled in size. “That’s the biggest thing we’ve learned over time,” he said. The benefits of meeting challenges head-on with wise management pay off in terms of a practice that is better able to manage its own caseload and deliver on quality, Shuford said. “We’re seeing the results of that, with less referrals outside our group, and the ability to give specialized care for some of the more advanced things like prostate cancer,” he said. “We will coordinate those into fewer people’s hands, and we’ll do it well, which provides better care for the patients, and helps the practice as a whole.”