Lessons From the Great Lakes

Raoul S. Concepcion, MD

Editor-in-Chief of

Urologists in Cancer Care

Director of Clinical Research Urologic Surgeon Urology Associates, PC Nashville, TN

In keeping with my recent missives and invoking some of my favorite music from the ’70s and ’80s, I was reminded recently by my good friend and colleague, Jim Bailen, MD, of the famous Gordon Lightfoot song, “The Wreck of the Edmund Fitzgerald.” Those of you who have ever had the opportunity to meet and interact with Jim (director of Clinical Research, First Urology, Louisville Kentucky), know that not only is he a great urologist and researcher, but one of the wittiest individuals you will ever have the pleasure to engage and an all-round good guy who I feel privileged to call a friend. And having been one of the founding partners of his group, he also possesses a very keen business acumen.

At a recent meeting, Jim and I were talking about the changing environment of medicine and the challenges we as urologists are currently facing, especially in light of diminishing reimbursement, rising overhead, and increasing government regulations. He went on to explain to me that physicians tend to practice according to the “Edmund Fitzgerald principle.”

For my fellow audiophiles and historians, many of you are probably aware that the Edmund Fitzgerald was an iron ore tanker that sank in Lake Superior in November of 1975, carrying a load from Wisconsin to Michigan in a particularly vicious storm of hurricane proportions, killing all 29 of its crew. Dr. Bailen, who had served as a physician in the Naval Hospital, Great Lakes north of Chicago prior to moving back home to Louisville, proceeded to tell me that it was commonplace and standard operating procedure that when these giant tankers encountered bad weather, they turned up their engines and tried to make port as quickly as possible. Many theories abound regarding what actually sank the “Pride of the American Flag,” but suffice it to say, the faster she went, the more water she took in, hastening her demise.

We as physicians, especially surgeons, tend to operate on the same principle: When things go bad, especially when revenue goes down, we just work harder and see more patients, with the expectation that it will correct and we can maintain. The reality of the situation, however, is that despite our best efforts, doing what we know how to do and maybe not being fully equipped with all the correct data, we may in fact be losing money and be on board a sinking ship.

Why do I bring this up? It is painfully clear that the solution goes well beyond just seeing more patients and operating more. Consider the following:

1. The government wants to move into alternative payment plans that go away from traditional fee-for-service options to those that are value-based, looking primarily at outcome metrics, as ill-defined as they may be, and patient satisfaction.
2. As a result of the USPSTF “D” recommendation for PSA testing, the number of prostate biopsies is down across the United States, impacting revenue, whether it be in your lab, pathology division, or surgery center.
3. With the number of biopsies down and more and more patients opting, appropriately so, for active surveillance for low-risk prostate cancer, the number of men choosing definitive therapy—whether it be surgery, radiation, or cryotherapy—is also on the decline, again impacting our practice revenue.
4. With sequestration, the sustainable growth rate, Obama Care, the attack on the in-office ancillary services exception, electronic health record mandates, and the plethora of all the regulations we face on a daily basis, the cost to do business continues to rise and there is only so much we can trim.

All of us need to critically examine how we are practicing in preparation for the changes that are looming. We should not compromise the care of our patients, but make sure that care makes fiscal sense. I know that some have abandoned in-house labs and advanced imaging. We have altered our policies regarding injections in the clinic, especially testosterone.

As I talked about in previous articles, we all need to consider adopting therapies and service lines and partnering with other healthcare providers in our areas. Whether that means developing clinical research, advanced therapeutics for cancer care, or centers of excellence across many urologic disease states, it will put us in a better position to manage our patients at the time of diagnosis and through the continuum of care. This will be critical, especially with the push for accountable care organizations.

Due to the nature of our specialty, we will more than likely always need hospital partners, and to continue to develop strategies that make it beneficial for us to co-exist. Remember that close to a third of new urology residents are signing on with integrated systems or hospital-funded groups directly out of their training. These systems represent the biggest threat to many specialties. I do not want the independent practice of urology to become flotsam and jetsam in the wreckage at the bottom of the healthcare system transformation, and the time to act is now, before the storm really builds.