LUGPA Aims to Help Practices Thrive: Leaders Discuss Progress and Goals

During the annual meeting of the Large Urology Group Practice Association (LUGPA) in Chicago in November 2013, the organization’s president, Deepak A. Kapoor, MD, completed his 2-year term and handed the gavel to incoming president Juan A. Reyna, MD.Urologists in Cancer Care sat down with both leaders to learn about the successes and challenges LUGPA experienced during Kapoor’s term in office and the issues expected to take center stage under Reyna’s direction.Kapoor is chairman and CEO of Integrated Medical Professionals, PLLC, in Melville, New York, and Reyna is with Urology San Antonio.

Deepak A. Kapoor, MD

Dr. Kapoor: Proud to Have Increased Organization’s Membership

UCC: What were the biggest issues you tackled during your term as LUGPA’s president?

Kapoor: One of the things I’m most proud about is that, over my 2-year term, membership has grown by close to 30%. At this point, more than a quarter of all urologists in the United States are LUGPA members, and nearly one-third of independent practicing urologists are in groups that are members of LUGPA. The greatest challenge we’ve been facing is the profound uncertainties that exist around the future of health care. We’re trying to cope with the changes that the Affordable Care Act is going to bring, but so many of the changes are so vague. We also have the continual uncertainty associated with the Sustainable Growth Rate, or SGR issue.

As the private sector is trying to cope with the healthcare exchanges and the expansion of the Medicaid program, urologists have the additional burden of dealing with the myriad changes that are going to be coming down in the Medicare system; in the average urology practice, 45 to 55 percent of patients are covered by Medicare, with the exception of certain subgroups such as pediatric urology. As a consequence, some of the regulatory changes in the Medicare system are of real concern. But we’ve been extremely active in Washington to tell the story of what our member groups can bring, especially in terms of providing tremendous access on a community level in an affordable and high-quality venue. Getting that message out has been extremely important for us.

The other great challenge we’ve seen is the mischaracterization of integrated, comprehensive health care. Unfortunately, this has occurred because medicine is a zero-sum game: If urology practices are providing services [such as radiation therapy, imaging, and laboratory services], that means other people are no longer providing those services. For a urology practice, these business lines enable us to control the quality of services needed to provide care for our patients, but they are extensions of our core skills. For other specialties, that’s all they do, and in an attempt to protect their revenue streams, they’ve resorted to gross distortions to attempt to recapture lost market share via legislative fiat. In the course of that debate, we’ve needed to combat misinformation about our use of in-office ancillary services. Fortunately, physicians in both chambers of Congress have recognized the importance of preserving patient access to these services.

Your organization is composed mainly of large urology groups, and there seems to be a trend toward smaller groups across the country merging and growing. What will this trend mean to the independent practice of urology?

Regardless of practice milieu, every urologist fundamentally has more in common with any other urologist than with physicians practicing in other specialties; therefore, our needs are extremely similar to each other. These synergies enable us to develop group practices in which we can practice at a very high standard while simultaneously reducing overheads through shared economies of scale. When you look across the United States, anywhere in the country where there’s enough population density to support group practice integration, you have seen LUGPA groups develop, often becoming dominant players in their market. It’s very important that people understand that having a large share of the market is not a violation of any type of antitrust rules. In fact, if you’re behaving in a pro-competitive fashion, market share is something that can be very positive and productive. It enables you to deal with third-party payers to ensure that compensation is fair and reasonable, prevent predatory hospital systems from limiting access to genitourinary services, and, most importantly, standardize services across a region to ensure that our specialty is practiced in accordance with the highest medical and ethical standards.

It’s my profound conviction that, going forward, the integration of urologists into larger group practice is going to be the backbone that ensures the survival of the independent specialty of urology. I’m really very excited about where we are as a specialty and where we are going.

With the field facing a shortage of urologists, what can be done to increase the number of new doctors taking up this specialty? Can LUGPA be part of a solution?

Let’s take a look at some of the fundamentals about urology: 1) There are already not enough urologists in the United States; 2) The need for urological services is going to be expanding as the population ages; 3) The attrition rate for urologists to death and retirement exceeds the graduation rate from urology residencies; and 4) The average age of the urologist is 55, making it the second-oldest specialty after cardiothoracic surgery. What you see is a situation where the relative undersupply of urologists—already dramatic in more rural areas in the country—is actually going to become much more profound.

This requires the coordinated efforts of not just LUGPA, but every urological society. There’s a tremendous need to have increased resources devoted to residency funding. And that will require us to abandon the historical town-versus-gown differences that have separated us.

We’re seeing an era in which the differences between academic urology and independent urology are becoming profoundly blurred. Community urologists can provide very sophisticated clinical services and produce similar patient outcomes as academic centers; simultaneously, academic physicians are finding it more and more necessary to support their departments on their clinical productivity. The opportunity exists right now to put aside those historical differences and work together on issues that are common to us. Certainly, one cause we can all work together on is to ensure that adequate resources are in place for residency training going forward, because getting the best and brightest minds into urology serves all of our interests.

As you prepare to leave office, how do you see this year’s LUGPA meeting benefiting urologists?

What’s exciting about this particular meeting is that the people here are exclusively thought leaders. Everybody here leads a group and everybody here is responsible for understanding recent regulatory changes, and not only explaining that to their doctors but implementing policies and procedures so their practices can adapt.

Because the people who come here are extremely high-level decision makers, the meeting provides the opportunity to network with other individuals who face similar challenges. If you are coping with a predatory hospital system, if you’re dealing with third-party payers that won’t negotiate, if you’re having problems getting your own practitioners to comply with your policies, it’s guaranteed that there’s somebody else here who has faced those problems and come up with real-world solutions.

This is the only forum in the world where the individuals dealing with those problems are here all at one place and one time. So I’m excited about what this meeting offers to our members, and I think that, as we go forward, this ability to brainstorm and network with other individuals who are dealing with the same issues is only going to become more valuable.

Juan A. Reyna, MD

Dr. Reyna: Opening Doors of Organization to Smaller Urology Groups

UCC: What are your top goals as LUGPA president?

Reyna:My vision is a little different from where we’ve been as an organization for the past several years. During that time, we’ve been fighting a battle in Washington, DC, to retain our right as large groups to offer in-office ancillary services. We have a tremendous team doing advocacy for us on the hill and protecting those in-office ancillaries, and I in no way want to diminish those efforts. But I do want to increase our efforts this year to try to give back to the rest of our membership. A lot of our members don’t have the big radiation units and the big pathology units and the CT scanners that the big groups have, and my hope is to give back to all the groups in LUGPA by providing for them the services, information, and initiatives that will help them grow and become more successful.

We did some rebranding this year, and our new logo is "LUGPA: Integrated Practices, Comprehensive Care.’ ‘ "Large"is nowhere included in that rebranding. Our hope is to start reaching out to smaller groups, touch base with them, and get a two-way dialogue going between what they need and what we can provide—and really sometimes what we need, since they’ve had successes that we can learn from, as well.

There are a lot of less-than-kosher initiatives out there driving people to think that they have to be part of hospital systems. I’m not necessarily saying that hospital systems are a horrible way to practice, but if urologists want to maintain their independence, we are trying to provide ideas for them in terms of collaborative efforts and other revenue-producing efforts.

You mentioned that one of those efforts involves a men’s health initiative in which LUGPA’s member practices can participate. Can you tell us more about that?

Here’s an excellent way of bringing more work to your practice, increasing your revenue. It’s an initiative that Dr Peter Knapp [of Urology of Indiana] started, called "Your Numbers Matter,"that is being kicked off here at this meeting. The idea is that men need to know certain numbers that are very important to them—their PSAs, testosterones, cholesterols—and we are providing an entire marketing package to all practices within LUGPA, for free, that will help them communicate with patients about this issue. We will provide posters and flyers that practices can display in their offices, and there are letters made out to patients and letters dedicated to referring physicians. There are a number of things that will be done under this initiative that are quite unique, and all the heavy lifting is already done. It’s just a matter of practices tagging their logos onto this initiative and making it their own.

What do you hope attendees have gotten out of this annual meeting?

At every meeting, we try to highlight the newest of the therapies available. We don’t do presentations that are pro or anti any particular drug, but just provide solid information about the treatments out there. My hope is that, when people come to the meeting, they do learn clinical information. But even more so, I hope they will get information about how to thrive within the current healthcare changes.

There will be a tremendous number of changes starting very soon, and there’s no reason why we each have to learn how to do any given method of reimbursement, for example, over and over again. We can start to share what is working, and what isn’t, when it comes to newer reimbursement strategies. We’d like to serve as a clearinghouse for that kind of information, so groups can say, "Well, the guys in Indianapolis are doing a very unique thing with the medical home concept; maybe that’s where we want to go with our accountable care organization in our city."