Is autonomy dead for the practicing urologist?

As solo and small group urology practices seek refuge from growing regulatory and economic burdens by joining bigger entities, urologists accustomed to calling the shots are wondering if autonomy is dead. Experts with the larger groups and health systems providing alternative models and much-needed economies of scale say autonomy, or maintaining control of how a urologist practices, isn’t gone entirely, but it is different.

Urologists might be happy to relinquish control of burdensome administrative tasks, including keeping up with evolving government regulations and payer demands. They’re often relieved to let a large group or health system administrator worry about making ends meet.

The struggles for many arise when they lose control of their ability to make all the decisions about how to care for individual patients, have to go through red tape to hire new staff or buy equipment, or can’t make choices about what hours they work or the amount of call they take.

Autonomy is a big concern among physicians, according to attorney Curt Chase, JD, chair of the health care, life sciences, and education business unit at Husch Blackwell in Kansas City, MO.

“It’s probably one of the biggest challenges of any transaction we work on-maintaining that level of autonomy on the issues that really matter,” said Chase, who represents both hospitals and physicians.

Next -Today’s reality: The independent practice modelToday’s reality: The independent practice model

Sixty percent of practicing urologists in the U.S. are in private practice, which includes solo, urology-only, or multispecialty groups, according to the recently released 2017 AUA Census (“The State of the Urology Workforce and Practice in the United States”). The percentage of employed urologists increased during the past 4 years to nearly 56% in 2017, the census found. A similar trend has been seen in results from Urology Times’ State of the Specialty survey over the past 4-5 years.

“The solo practitioner is in total control of their environment, and some people require that, though it’s increasingly hard to make a living. Other people don’t care about being in control of their environment, so they’re happy to work for a large health system,” said Gary M. Kirsh, MD, president of The Urology Group, a 39-urologist group with 12 locations in the Cincinnati area. “And then there’s a group of people in the middle who prefer what we call independent practice.

“But independent practices are getting bigger and bigger and are starting to have different looks to them. If you’re a group of 39 doctors, are you in independent practice? Well, sort of because you’re not owned by a hospital, but you have to go along with the will of 39 other people.”

In independent practices, the bigger the group, the further away individual physicians are from true independent decision-making. The trend, according to Dr. Kirsh, is for groups to want to join, even crossing state lines, to achieve the size needed to succeed in the current health care environment.

How urologists manage their patients in big groups also balances autonomy with oversight.

“In the old days, whether you were in a solo practice or one of 39 doctors and you wanted to treat any patient you saw in any way you wanted to, that was OK,” Dr. Kirsh said. “In the new health care world, that is not going to be OK. It doesn’t mean that every patient is treated by a formula-far from it. But the need to follow some guidelines and having reasons why you don’t follow guidelines in specific patient care scenarios is becoming increasingly important, because we’re going to have to function that way in a value-based world.”

In essence, if the group agrees to contract with a payer that has certain care pathways, urologists in the group are going to have to increasingly learn to swim in those lanes, Dr. Kirsh said. And that’s not easy for doctors.

“Medical training fosters rugged individualism, and we’re running up against the fact that in a consolidated health care world, that rugged individualism isn’t what’s being desired,” Dr. Kirsh said.

David Chaikin, MD, a urologist with Garden State Urology, Morristown, NJ, was part of the trend for practices to consolidate in 2008, when the group with which he practiced joined several other urology practices in the area to form Garden State Urology.

“We did it to be able to compete with the hospitals and to remain relevant,” he said.

Dr. Chaikin is an equal partner and decision-maker with other founding urologists in the group. Because he has ownership in the practice’s direction, Dr. Chaikin said he thinks the independent urology group is the closest thing, in terms of autonomy, to the small or solo urology practice.

“Starting a private practice, we all wanted to be masters of our own destiny. I think going into a health system, you’re going to lose that ability. Staying as an independent group is important so that you can fulfill what you want to do, which ultimately is to take care of patients by providing the best care that’s out there. But in order to do that, you need some scale and resources,” Dr. Chaikin said.

Next: Finding autonomy in a health systemFinding autonomy in a health system

Urologists at Cleveland Clinic have a lot of autonomy on how they manage patients, according to Eric Klein, MD, chair of the Glickman Urological & Kidney Institute at Cleveland Clinic, Cleveland.

“Urologists are free to manage patients the way they see fit, based on their expertise, as long as it’s within certain quality guidelines,” Dr. Klein said. “We realize there are guidelines but still some variability in the way certain patients like to be managed based on their individual circumstances. So, from that standpoint, I would say there’s still a large amount of autonomy.”

But there are other areas in which urologists don’t have as much decision-making ability as in the past, Dr. Klein said.

“The days of having independent physicians in individual practice and small groups decide what the scope of their services is, what hours they want to work, where they practice-all of that kind of thing-that’s just not economically viable anymore, nor is it viable from a regulatory standpoint,” Dr. Klein said. “When we have physicians approach us about joining us, it’s in large measure because of the regulatory burden and so forth, which big institutions do a great job with because there’s an economy of scale.”

Mayo Clinic does a great job allowing its urologists to practice as they see fit, according to Daniel S. Elliott, MD, professor of urology at Mayo Clinic in Rochester, MN.

“With that said, everything we do and surgeries we perform are reviewed for quality assurance. From that perspective, we have a lot of oversight, which others might not. In my opinion, it is a good thing-a good balance. They let me do what I want. But I also have to be a responsible, good surgeon. I can problem solve as I see fit. It’s a balance where I’m free to think but I’m also going to be responsible for what I do,” Dr. Elliott said.

But similar to Cleveland Clinic, urologists at Mayo Clinic might find it more difficult than in the past to hire staff quickly, or at all, for example.

“One of the difficult or potentially frustrating things is I’m involved in a very big organization, so I don’t have the ability to hire and fire individuals as I see fit. That could be a good thing; dealing with personnel can be a big pain. So it’s a balancing act,” Dr. Elliott said.

There is no perfect job out there-even in solo practice, according to Dr. Elliott.

“I think the key is finding what fits your personality. I love working at Mayo. It fits my personality perfectly. I love the challenging cases and all that,” Dr. Elliott said.

Next - Autonomy: Is it negotiable?Autonomy: Is it negotiable?

Autonomy isn’t negotiable in many large groups, Dr. Kirsh said, because successful groups have visions, cultures, and missions. Urologists integrate into those groups, and while they have a say in what goes on, it’s shared decision-making.

There are models within large health systems that encourage autonomy among urologists. One example: Cleveland Clinic purchased a hospital about 35 miles from its academic center in Cleveland.

“There was a urology group there of 14 individuals, and they expressed an interest in joining us. They liked the style of medicine we practice, and they had built up many personal and referral relationships with our subspecialists over several decades,” Dr. Klein said. “So, eight of the 14 practitioners decided to join us.

“We have set them up as a separate operating unit. They still have the autonomy to manage their patients the way they see fit, within certain quality guidelines. But they have their own administrator, nursing staff, medical assistants, and advanced practice providers. And even though they’re now employees of the Cleveland Clinic, their lives haven’t changed that much because we allow them the local autonomy to manage their office and practice in the same way that they did before.”

A similar structure that is becoming more popular is called the group practice subsidiary model, according to Chase, the attorney.

“It’s a model where physicians are integrating into the health system, without actually selling their practice, and maintaining a lot of autonomy on the day-to-day decisions affecting the practice,” he explained.

In the traditional employment model, where hospitals or health systems employ physicians and take all the economic risk, physicians give up virtually all their control, according to Chase.

Physicians want to control their office hours, hire staff, and buy equipment when needed, Chase says.

“If you’re an employee of a hospital, there might be 15 layers of bureaucracy,” he said. “In the group practice subsidiary model, all those kinds of day-to-day operational decisions stay with the physician. The group practice model threads the needle between both autonomy and integration.”

The model involves setting up a new entity-a subsidiary of the hospital. It has a board that is a majority of physicians. The hospital has certain veto rights and oversight powers because it owns the entity but does not subsidize the practice. Physicians remain economically at risk.

“One advantage of the model from an economic standpoint for the physicians is that because they’re integrated with the hospital, they are able to participate in the hospital commercial contracts,” Chase said.

If the partnership doesn’t work, there’s a built-in safety net. Since physicians still own their old practice’s assets and the old entity, they can terminate their employment with the new entity and go back into private practice. That would be almost impossible if they had sold their practice to a hospital, particularly if the employment agreement with the hospital contained a non-compete clause, according to Chase.

Next: Embracing realityEmbracing reality

Brian R. Stork, MD, and his partners recently sold their small group private urology practice to join the department of urology at the University of Michigan.

“Although each of us had different reasons for wanting to make the transition, I personally felt like I was becoming more and more like a hamster on a wheel trying to keep up with all the regulation and business challenges of private practice,” Dr. Stork said.

Dr. Stork said he used to think of autonomy as being synonymous with control.

“Historically, in this way, a physician’s clinical practice and business was a reflection of his or herself,” he said. “In recent years, however, changes in regulation and reimbursement have served to really challenge and erode physician autonomy as we once knew it. Now my idea of being autonomous is, paradoxically, working with a large group of colleagues I respect and enjoy and doing the many different aspects of clinical practice, research, and community service I genuinely like to do.”

At the end of the day, whether a urologist has more autonomy or less autonomy, in a practical sense, isn’t the overriding issue, Dr. Stork said.

“If you fail to adapt to a changing environment, you run the risk of becoming extinct,” he said.