Management of a urology office—large or small—is fraught with challenges, particularly in an era of rapidly evolving regulatory and fiscal environments. Increasing costs and decreasing reimbursements have forced practices to adapt by offering new products and services, maximizing business efficiencies, and forming strategic alliances. The following interactive discussion highlights the challenges and outlines potential solutions for the issues faced by today’s urology practices, especially in adopting new treatment options for advanced prostate cancer.
Gary Kirsh (Moderator): As practice administrator, what would you say are the foremost practice management challenges in the CRPC landscape right now?
Debbie Barnes: My biggest challenge is non–physician staffing—not having enough time to do all the things we need to do for our CRPC patients. Our staff is currently overwhelmed, so we need to look at our staffing models to see if we can reallocate anyone. Another option may be to hire more staff.
Kirsh: Sharon, is your group facing similar challenges in treating CRPC?
Sharon Rouleau: We’re a relatively large practice, and we really haven’t had too much of a challenge with staffing. I think our biggest challenge is in our relationships with the (medical) oncology providers in our area, particularly with regard to treatment recommendations. There are local oncologists who also see some of our patients. They are advising some of these patients to choose a different course of therapy than what was recommended by our providers. Unfortunately, we are finding that the oncologists don’t communicate their recommendations to our physicians—instead we hear about them from the patients. In my opinion, that’s been our biggest hurdle in treating CRPC patients.
Kirsh: Kathy, what has been your most important challenge in adopting newer therapies?
Kathy Hille: We’re an 18-urologist group, and we do not have a physician champion in the oncology arena. Our compensation model is not set up to encourage internal referrals. Even if we had a physician champion or two, I fear there would still be reluctance to refer within the group and let that patient go. That’s how I see it from an administrative perspective.
Kirsh: Kathy, I think your candid comment applies to many of the large urology groups in the country. It’s an extremely important concept, and the reluctance to make specialty internal referrals may hamper groups from progressively embracing new therapies as well as the new reimbursement models that we’re going to see.
What about challenges when you first begin adoption of some of the newer therapies that have become available for advanced prostate cancer?
Rouleau: Manufacturer support is critical, and overall, they have done a good job in supporting us. First impressions are also very important when it comes to reimbursement for a new product. The one thing you don’t want as a practice is to have a bad experience with reimbursement early on, because once you have a bad experience, then adoption of the product gets shut down before it can begin. Fortunately, we really haven’t had any such problems.
Carol Sather: When the office first begins prescribing a new therapy, it’s important for the practice manager to closely monitor the therapy and not delegate this task to office staff. You really have to watch the first couple of prescriptions that come through so you can inform your physicians, and your vendors, if any problems arise.
Hille: I agree. In our practice, the business office manager takes on new therapies personally, handling the first 4 or 5 cases, and then delegating to a select supervisor within the group. So I think use of these new therapies requires very close attention until the process works like a really well-oiled machine. Occasionally we will encounter challenges with very needy patients who ask detailed clinical questions that we have to refer back to the satellite office. Sometimes it can be a challenge to communicate clearly with these patients and handle their needs with sensitivity.
Kirsh: I wonder if you can provide some additional insights regarding operational issues. For example, are the PAs done by satellite office staff? Are the copays collected across the organization the same way?
Barnes: We have a single location, so the process is very simple operationally. I have 1 person responsible for PAs for the entire practice.
Hille: Our PAs are done by location. We have ancillary services in our corporate office where I am, but all of the general urology locations are in the periphery. There is 1 person in each office who gets the PAs and follows through on them. If it is a 1- or 2-physician office, PAs are probably not a big part of that person’s job. However, if there are 6 physicians in the office, that person is devoting a considerable part of their time getting PAs approved.
Sather: We have 3 offices. For surgical procedures, each office handles its own PAs. For a new product such as Provenge, I became personally involved with all requests at first, because the payers were requesting a lot of information and it made sense to have a single point of contact.
Earl Walz: For Provenge, we also centralized the process into the corporate office. When you start talking about PAs, you need to distinguish between more sophisticated medications and the usual OAB [overactive bladder] drugs, BPH [benign prostate hyperplasia] drugs, and ED [erectile dysfunction] drugs. These more common medications have more routine patient requirements and the PAs are done in our satellite offices.
Kirsh: What about consistency—are PAs relatively standard for different payers or do you need to provide 5 sets of data for 5 different payers?
Sather: We see different PA and medical necessity requirements for different payers.
Kirsh: It’s all over the board?
Hille: I agree with that.
Deepak Kapoor: In addition, the requirements are different for Medicare patients.
Kirsh: Thank you for providing those insights. Clearly this is an important issue for urology practices.