Change may not always be pleasant, but it is inevitable, and nowhere has that been more evident recently than in US healthcare; however, for the physicians at Regional Urology in Shreveport, Louisiana, these changes are really just business as usual.
Regional Urology campus in Shreveport, Louisiana
Change may not always be pleasant, but it is inevitable, and nowhere has that been more evident recently than in US healthcare. The impact of the Affordable Care Act can be felt across the entire spectrum of healthcare. Those changes and updated practice guidelines—most notably the debate over the value of the prostate-specific antigen (PSA) test as a cancer screening tool—have rocked the boat for many urology practices.
But for the physicians at Regional Urology in Shreveport, Louisiana, these changes are really just business as usual. For instance, the American Urological Association (AUA) recently released guidelines (http://tinyurl.com/cc67nt6) on how to use PSA-based prostate cancer screening in asymptomatic men, calling for the test to be reserved for men ages 55 to 69 after a discussion between physician and patient.
“These new guidelines basically describe what we’ve been doing all along: using the PSA test appropriately to make sure that the right patients get screened,” explained urologic oncologist Jonathan Henderson, MD. “The only substantial change was moving the age from 50 to 55 for the start of screening. These guidelines have a good scientific basis—unlike the US Preventive Services Task Force recommendations— but they’re not really new to us.”
Jonathan Henderson, MD
As for the ACA and its mandate to provide high-quality, cost-effective care, Regional Urology has embraced that model since the practice opened its doors over a decade ago.
“We’ve made patient care and convenience a priority,” said CEO Joel Young. “There are many regions where patients may have to wait a week or two to be seen by a urologist, even for something as simple as a kidney stone. Here, the patient can arrive with undiagnosed pain, receive appropriate testing to make a diagnosis, undergo treatment, and head home by noon. Our goal has always been to offer high-quality, cost-efficient healthcare.”Regional Urology had its first incarnation in 1998, when two local practices joined forces. Eventually, a third group merged into the practice, but each group maintained its own offices. In 2001, after several other practices joined Regional Urology, the group decided to build one main office to house its 140 employees, including 15 physicians. The practice, which also has a satellite office in nearby Bossier City, Louisiana, sees patients from around the state, as well as others from Texas, Arkansas, and Oklahoma.
“Even though we were just a backwater of Louisiana, we built a 50,000-square foot-plus campus with office space, clinical research space, an ambulatory surgery center, and a radiology department, all in one place,” Henderson said.
In 2005, the practice opened an Oncology and Radiation Treatment Center, currently headed by Rod G. Krentel, MD. As it always does when considering expansion, the practice had the integrated care model in mind when it added the unit, Henderson said. Being able to offer on-site radiation treatment to patients, he said, brought the practice closer to its goal of being “the urologic Mayo Clinic of the South.”
While urology practices that have integrated radiotherapy services have seen their fair share of scrutiny for possible overutilization of the modality, Young and Henderson agreed that contending with that kind of criticism is well worth it.
“We brought this technology to our town because this treatment option didn’t exist here before,” Young pointed out. “To some extent, there was an increase in the utilization, but that’s because the technology simply wasn’t available.”
“This morning, I had a prostate cancer patient who came from 100 miles away,” Henderson added. “He was not a good candidate for robotic prostatectomy, which is what he was sent to me for. We talked about other treatment avenues, and he was able to walk over to the radiation center and see the radiation oncologist on the same day.”
Henderson cited data from a 2011 study that found that intensity-modulated radiotherapy utilization rates at urology clinics were similar to those at outpatient hospital facilities, challenging the idea that private practices are indiscriminately shuttling patients toward this treatment (J Urol. 2011;186(3):860-864).Louisiana’s obesity rate is nearly 35%, according to 2011 figures from the Centers for Disease Control and Prevention. Of course, excess weight can increase a person’s risk for multiple urologic conditions, including prostate cancer.
For clinicians at Regional Urology, that means tackling an uncomfortable subject with patients. Henderson described two such patients with prostate cancer whom he’d seen recently.
“I spent half [of their] visits talking about their nutrition and diet,” he said. “One of them has been on active surveillance for 4 years, and I noticed that he’d gained 20 pounds in the last 6 months. The other is an advanced prostate cancer patient. He’s been through several treatments and has a good chance of long-term survival, but he is morbidly obese. I asked him, ‘Does it make sense for you to have gone through all that treatment and everything that we’ve been through, only to have you die of a myocardial infarction because you are overweight and not taking care of your cardiovascular system?’”
Indeed, the obesity/urologic disease connection is an area that urologists are going to have to focus on more, starting with in-office education, because patients don’t always see the link, Henderson said. “Patients are surprised when I discuss weight issues,” he said. “They look at me with such shock: ‘Why would you talk to me about my weight?’ Once I educate them, it does make a big difference, but it’s something that urologists need to do. It’s not something that we are going to get reimbursed for, and it requires extra time, but it’s worth it.”
That’s one reason that Henderson said he believes urologists have the upper hand when it comes to treating urologic cancers. In some cases, he’s seen these patients for decades, and strong bonds have formed.
“Emotional and mental health play a major role in an advanced cancer patient’s longevity,” he said. “I think maintaining that healthy bond does nothing but good for the patient. In my experience, you can visibly see a patient’s face fall when you tell him that it’s time to see the oncologist. Their perception is that you’ve just handed them a death sentence. The longer we can keep the patients, the better their mental health is going to be, and that can only improve their outcomes.”Advanced prostate cancer has seen tremendous advancement in treatment options in the last few years with drugs like sipuleucel-T and abiraterone, but those treatments come with a significant price tag. Yet, according to Henderson, it’s not the cost of urologic cancer care that has changed all that much; it’s more a matter of who is managing those costs.
“As urologists, we’ve been used to thinking in terms of quick, decisive surgical cures,” he said. “If the patient had a more advanced cancer, then we’d send him to the oncologist and we wouldn’t necessarily see him again. So those cancer care costs were being incurred, just not by urologists. Now that we are starting to treat those advanced prostate cancer patients, we are having to look at those costs.”
Another financial issue the practice contends with is competing with hospitals over an increasingly smaller pool of new urologists. Henderson described the manpower shortage as a “soapbox” issue that he’s passionate about. He said there are good reasons for young urologists to join practices like his own.
When he discusses the urology career track with residents, Henderson highlights the fact that personal development is as important as monetary stability. To that end, he said, a large-group practice like Regional Urology allows a physician to subspecialize and find a steady career path that is more likely to withstand any future changes in the healthcare landscape.
“The hospitals have deeper pockets,” Henderson acknowledged, “and for a lot of residents, after years of low pay and incurring substantial debt, the hospital salary looks good. But how long will that last, especially once the ACA kicks in? For now, the hospital is paying well, but when it comes to the point where it’s no longer in their best interest to pay their physicians as much, then what happens?”
“When you give up your autonomy to a hospital as an employee, you are subject to their rules,” he added. “Autonomy is important for most physicians, and without it, you aren’t always allowed that personal development.”