With Its Long History and Pioneering Spirit, Urology of Virginia Faces a Changing Landscape

Michael Fabrizio, MD

Urologic practices, both small and large, find themselves at a crossroads given the current healthcare landscape. Pressure from many sides, especially from regulatory and clinical challenges, places today’s urologic practice in a precarious position. The health reform landscape, which emphasizes the shift to a value-driven versus volume-driven model of care, poses unique challenges that urology practices have never faced before. The explosion of new therapeutics developed for the advanced prostate cancer setting can challenge urology practices to provide their patients with the latest and most optimal care. In addition, with hospital care hovering around 3 to 6 times the cost of outpatient care, many urology practices are finding that they cannot just sit back and merely practice medicine.

Founded in 1922 by Charles Devine, Sr, MD, the Urology of Virginia practice is instilled with a pioneering spirit demonstrated throughout its history. In 1952, his son, Charles Devine Jr, MD, joined the practice, followed by his other son, Patrick Devine, MD, in 1957. The elder Devine eventually became a world renowned specialist in male pelvic reconstructive surgery. By chance, the presence of a plastic surgeon during one of his surgeries sparked a collaborative effort that resulted in countless innovations in urologic procedures.

OncLive: You opened the Paul F. Schellhammer Cancer Center in 2012?

The Devines established a urological residency in 1965 at Norfolk General Hospital. They were also instrumental in the organization and establishment of Eastern Virginia Medical School where the current urology residency resides. OncLive spoke with Michael Fabrizio, MD, CEO of Urology of Virginia practice, as well as Dana Adams, COO, to gain their perspective on the challenges that urology practices face today.Dana Adams: Yes, the cancer center was dedicated in 2012 to Paul F. Schellhammer, MD, senior partner at Urology of Virginia. Dr. Schellhammer has been a physician with the practice since 1974, and a faculty member of Eastern Virginia Medical School since 1978. He served as chair of the EVMS Department of Urology Healthcare Professionals Network http://bit.ly/28kxU5z from 1989-2000.

What kind of services do you provide your patients?

We now have 32 urologists as well as physician assistants, nurse practitioners, and nearly 300 employees.Michael Fabrizio, MD: We offer an infusion center to administer immunotherapy. We offer a specialty pharmacy to provide patients with access to oral oncolytic medications. We now have a state-of-the-art ambulatory surgery center, which is opening up in June on the second floor. The ambulatory surgery center was created through a partnership with Chesapeake Regional Medical Center, a local hospital system, to provide convenient and easily accessible surgical care. On our first floor, patients will find cutting edge imaging services offered through a private company called MRI & CT Diagnostics. That company offers the newest 3T magnet 64-slice CT scanner and bone scan imaging for our patients. Because the services are not hospital-owned, they are the lowest cost option in Hampton Roads and in the entire geographic area.

Virginia is a Certificate of Need state. How does this affect your practice?

Moving onto bladder cancer, what developments have you excited?

How about renal cell carcinoma? What’s new and exciting in this disease?

The American Urological Association meeting just ended. Did you attend and what was exciting there?

MF: A state with this designation requires approval by the planning district for any proposed acquisitions, expansions, or creation of facilities. Of course, all the hospitals in the state comply with this certification. However, very few independent physicians are able to obtain a certificate of need. But, as you are well aware and as you have probably seen in the media throughout this year, hospital-based care is exceptionally expensive. In-patient hospital care is typically three-fold higher than care provided in an outpatient setting. In the state of Virginia, our costs are kept artificially high by the fact that there’s a certificate- of-need issue. We’re hoping that that will change in the next year to come. We could offer more comprehensive care in our center, like providing our own intensity-modulated radiation therapy (IMRT) services, except we are in a Certificate of Need state. A lot of other urology practices in the country provide IMRT as another treatment therapy within their practice. But, unfortunately, with our state regulations we can’t have that.MF: In May, the FDA approved a therapy for patients with more advanced bladder cancer called atezolizumab (Tecentriq). Tecentriq is a PD-L1 inhibitor, which is indicated for patients with locally advanced or metastatic urothelial carcinoma (mUC), or within 12 months of receiving platinum-containing chemotherapy, either before or after surgery. I expect to see more PD-1/ PD-L1 inhibitors gaining regulatory approval in the next months to years. It’s the newest therapy in the last 30 years in bladder cancer, so we’re excited to be able to offer this to our patients.MF: I think an exciting development is that we can take care of renal cell carcinomas that are localized in a much more minimally invasive fashion, due to the advent of robotic partial nephrectomy. But there are exciting therapies for patients to receive in the neoadjuvant setting prior to treatment or post-treatment, and several therapies that are available orally for these patients.MF: Overall, there was a lot of excitement around potential therapies for advanced prostate cancer, especially in the M0 or M1 space. But I think what’s really interesting is how we are managing patients with low-volume prostate cancer. That is a field that has really been revolutionized over the last couple years with respect to active surveillance, and I think we are getting a better handle on which patients we can place in this category as opposed to treat.

In addition, we can use genetic markers now. There is a variety of genetic markers that can actually help us delineate which patients may be at risk to develop progressive disease or we can actually use magnetic resonance imaging (MRI) in a more effective fashion to identify lesions that may be more lethal.

What would your recommendations be to a midsize practice or even a small practice about financial viability?

The information provided by the Canary Foundation, especially in early disease detection, is important. The Canary Prostate Program, which includes the Prostate Cancer Active Surveillance Study (PASS), is a large tissue microarray biomarker project involving innovative imaging techniques. It is designed to address urgent, high-impact challenges in prostate cancer.DA: I would say the most important ability for the practice is to continue recruiting physicians. There is an overall shortage of urologists and that is only expected to continue. Recruiting is something to focus on for the future. Second, practices now need to keep one step ahead of all the government regulations such as HIPAA, upcoming changes to Merit-Based Incentive Payment System (MIPS), and different payment methodologies. Keeping abreast of those changes and continuing to change as regulations change is paramount. Third, new treatment options and surgical treatments should be incorporated into the practice that can be offered to patients. I think those are the three big things to ensure viability moving forward.