A Sizable Success: UroPartners Balances Operation of Large Practice with Provision of Singular Care

Brett Trockman, MD

One of the ongoing debates in US politics involves the pros and cons of big government versus small government: Does big automatically equal bureaucracy and groupthink while small inherently fosters individual creativity and enterprise?

The physicians and staff at UroPartners in Chicago have achieved what generations of politicians have struggled with—building a large organization that exists to support its individual stakeholders. Ready to celebrate its 10-year anniversary in July, UroPartners has more than 30 offices in the Windy City and its surrounding suburbs. There are more than 60 physicians with the practice; in addition to urologists, there are affiliated pathologists and radiation oncologists. The support staff numbers over 300.

“Some large-group practices will have a huge bureaucracy,” acknowledged Brett Trockman, MD, UroPartners’s medical director. “Sometimes, the centralized administrative office can take on more importance than the ‘boots in the field’ who are actually taking care of patients. We recognize that the physicians and the clinical staff are the most important component of our practice as they interact with patients on a daily basis.”

“Our job as a large-group practice is to support that talent,” he added. “It’s not our job to micromanage every patient interaction.” Trockman, along with President and CEO Richard Harris, MD, discussed how being a large-group practice has allowed them to implement the new rules and regulations of health care while staying true to UroPartners’s commitment to always putting its healthcare providers and patients first.

The EHR Era

UroPartners was formed when a number of smaller groups in the Chicago area decided to join forces; looking down the pike, the founding members knew that multiple challenges lay ahead in the healthcare environment, including the implementation of an electronic health records (EHR) system.

“Our biggest challenge was implementing EHR,” Trockman explained. “That was expensive and tough; it changed the way we interacted with patients.”

UroPartners began its EHR implementation in 2010 and has been working with the system ever since. On the upside, EHR has become the go-to modality for practice members when it comes to communicating about patients internally and maintaining cohesive care.

“For patient-specific issues, we utilize our EHR. That’s basically the only way we communicate about patients for [Health Insurance Portability and Accountability Act] reasons. And that’s really the best way for us to share patient information,” Trockman said. “So my notes about a patient will be available to the radiation oncologist or the next physician that the patient will see within the practice.” On the downside? “The thing I dislike about EHR is that patients wind up talking to my forehead because my head is down, keeping up with data input,” Harris said. “That makes the physician-patient interaction a bit impersonal. But for intragroup communication about patients, it’s turned out to be pretty useful.”

Trockman and Harris agreed that they couldn’t imagine adopting an EHR system as a small practice. Indeed, news articles abound about physicians in one- or two-person practices struggling to make EHR work for them. A 2013 report from the RAND Corporation, titled “Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy” (http://tinyurl.com/q4duuhk), found that physicians’ frustration related to EHR negatively influenced their attitudes toward their careers and medicine overall; some doctors even pointed the finger at EHR adoption struggles as the reason for their early retirement.

“I can only imagine how daunting it would be for a small physician group to try to implement EHR,” Trockman said. “We were fortunate in that we could bring in outside experts to help us through the process, and try to make it as painless as possible for our physicians and staff. That is one of the benefits of being in a large group and being able to use, and afford, those kinds of resources.” UroPartners is now going through the same process with ICD-10. For that, the practice turned to another large group for guidance.

“We had an expert in ICD-10 coding from Chesapeake Urology Associates [of Maryland] come in and work with us on that, give us a preemptive look at what it’s all about,” Harris said. “We often work with other large-group practices, because we have enough in common in terms of our structure to be able to learn from one another. A smaller group won’t necessarily have that kind of network.”

Urologic Cancer: Clinical Gains, Cost Concerns

UroPartners is particularly proud of its cancer care program as the practice, once again, balances being a large group with keeping individual patients front and center.

“For our cancer services, we are fullspectrum,” Harris said. “We have our own uropathology lab. We offer all the treatment services—intensity-modulated radiation therapy, brachytherapy, cryotherapy. We believe that we are able to provide better continuity of care. We have the size and the resources to do that.”

The practice has two centers that are devoted specifically to prostate cancer treatment. Harris’s clinical focus is on metastatic castration-resistant prostate cancer (CRPC), and the fact that his patients can receive their diagnosis, care, and after-care at UroPartners is a prime example of how the practice manages to be large yet offer a personalized touch.

“I constantly tell the group that it’s important that we, as urologists, keep these patients. For the most part, they don’t want to leave us to go to medical oncology, unless they require chemotherapy, of course,” he said. “In some cases, we’ve had these patients for 10 to 20 years. They’ve established relationships with us, and we have such great treatments—abiraterone [Zytiga], enzalutamide [Xtandi]—for this disease. I think all urologists need to be well versed in how to utilize these drugs in metastatic CRPC.” That same approach applies to other urologic cancers as well, such as the less common testicular cancer. Many patients with that condition are younger men who have to contend with issues beyond the scope of their disease and immediate treatment, like long-term fertility and survivorship.

“I think we need to recognize that for these younger patients— testicular cancer patients undergoing chemotherapy—we are obligated to continue to advise them after treatment,” Trockman said. “In a way, we become primary-care physicians for some of our patients, because we get to know them so well. It’s important to meet some of their emotional needs and help refer them to further support services.”

Being able to offer full-scale care doesn’t come without costs, and the price tag associated with cancer care has received its fair share of attention. It’s a difficult subject to discuss with patients, but Harris and Trockman concurred about how to approach it— don’t, at least not straightaway.

“My feeling is that we have to be physicians first, and focus on treating patients to the best of our abilities,” Harris explained. “Of course, cost is an issue. But I offer the best and most suitable treatments to my patients—until the time comes that we’re told that a certain treatment may not be an option because of cost. As the physician, it’s not my place to deny someone a treatment because of the cost.”

Trockman added that he doesn’t think dialogue about the cost of treatment takes place very often between physicians and patients in medicine in general. “I think that’s more of a health policy discussion. It is an important issue, but when it comes to the individual patient and the physician, I think this has to be a patient-driven discussion,” he said. “Even with the Affordable Care Act, patients are not in a position where they have to consider costs up front, and I think that would be the main driver of lowering healthcare costs.”

However, serving as an advocate for patients to obtain insurance coverage for their cancer care is one area where UroPartners uses its large-group status very effectively.

“We always go to bat for our patients with their insurance companies in order to get their care covered,” Trockman said. “Again, because of the size of our practice, we have the support staff to help the patients through this process and that kind of decision making.”

Long-Term Outlook

Moving forward, UroPartners will continue to offer what Harris called “superb quality medicine in a community setting.”

A major part of maintaining high-quality medicine will be working with urologic cancer patients on improving their general health. “We have a responsibility to look at our patients as a whole, and not just (at) urologic issues or their cancer issues,” Trockman said. “We know that cancer patients who have a better performance status do better in terms of their cancer treatment outcomes. And with some of our slow-growing cancers, it’s clear that the leading cause of death in these patients is cardiovascular disease. So we can’t just focus on the cancer itself.”

The practice also will have to consider future growth in the aftermath of major changes in the healthcare landscape. A decade ago, Harris noted that convincing physicians to join a large group took time and a bit of persuasion. That may be less of an issue with newer doctors, who don’t have preconceptions about how medicine should work. But they are still uncertain that bigger is better.

“I was just interviewing someone who has recently come out of residency and he said, ‘I don’t know what it’s like to work for a small group, or a hospital, or a large-group practice. It’s all new to me,’” Harris recounted. “But it’s still a challenge to get them to see what a large-group practice is all about; to get them to see that, even though they may be working miles away from their colleagues and in different offices, there’s still a sense of cohesion, both among our staff and between our physicians and patients. I think that sense of cohesion is where we truly excel.”